Book i-iZ 

Copyrights^ 

COFHIIGHT DEPOSIT. 



PRINCIPLES 

OF 

SURGICAL PATHOLOGY 



FOR THE USE OF THE STUDENT 



BY 



CARL BECK, M. D. 



PROF. OF SURGICAL PATHOLOGY 

UNIVERSITY OF ILLINOIS 
AND CHICAGO COLLEGE OF DENTAL SURGERY 



PROF. OF SURGERY 

POST GRADUATE SCHOOL, CHICAGO 



CHICAGO 
T. KEENER & CO. 
90 WABASH AVENUE 
1905 



LIBRARY of GOf^SRcSS 
Two Copie-3 He^sfveci 

JAM 30 1905 

Oou^n^iii tiiiry 




Copyright, 1905. 
W. T. Keener & Co. 



PREFACE. 



It would be ideal if the student could learn Patholog}^, which 
forms the foundation of his knowledge, on the living and on the 
cadaver, macroscopically and microscopically, by direct demon- 
stration. Such is, of course, out of question in the present methods 
of teaching with the number of students and the amount of ma- 
terial at the disposal of the teacher. 

Didactic and theoretical teaching is next to valueless. Expe- 
rience has taught me that the best method to teach surgical 
pathology was to demonstrate as many as possible fresh pathologic 
specimens; if this is impossible, preserved specimens: and then to 
examine microscopically as many pathologic conditions as possible. 
But the students impress the pictures of the miscroscope far bet- 
ter upon their minds if they themselves draw from the specimen, 
and they understand the drawings better; this is the reason why 
I have not appended any drawings to this book. 

My method is this: I distribute to 125-150 students in two 
hours lectures five or six pathologic specimens, draw and demon- 
strate on the blackboard these same. The nature of the pathologic 
changes to be studied has been given to the students before and 
they study them theoretically at home. During the lecture they 
correct their ideas about the changes which they have gained by 
theoretical studies and draw from the microscopic specimen cor- 
rect figures, which remain longer and clearer with them than the 
best drawing of the artist. • C. B. 



INTRODUCTION. 



Surgical pathology is that branch of pathology which deals 
with the changes of the human body peculiar to surgical diseases, 
viz. : those which are amenable to surgical treatment. Inasmuch 
as the field of surgery has changed from time to time, and is con- 
stantly enlarging, the field of surgical pathology is also variable. 
It is not the object of the science to divide pathology distinctly 
into two parts : one surgical and the other medical, but this divi- 
sion is made merely as a matter of convenience. Besides, surgical 
diseases have so many pathologic changes strictly characteristic of 
them that such a classification is logical. 

Before entering into the discussion of these particular 
changes we must state some facts which hold good for the general 
pathology of the body. A human body of ideal health and abso- 
lutely normal conditions is a rarity; perhaps it never exists. It 
would be a body in which every organ, in its minutest detail, 
would correspond with the ideal state as found by comparison of 
many, and it would be hard, perhaps impossible, to prove such a 
state with our many methods of investigation. The normal con- 
dition of the body is, therefore, only a relative one. JSTeither are 
the pathologic conditions well-defined types ; for example, erysipe- 
las is an infectious disease of the skin, which shows a characteristic 
appearance of redness, swelling, and eventually blister formation, 
fever, etc. In most cases the pathologic conditions will corre- 
spond with this picture, but there may be erysipelas without red- 
ness, without swelling, or any of the characteristic symptoms, only 
revealing itself by the same consequences, the same subjective 
symptoms, or only diagnosed by comparison with other cases 
occurring at the same time. If all these exceptions and varie- 

2 



ties were embodied in primary teaching, it would perplex the 
student. 

I shall endeavor to give, in my descriptions of pathologic 
conditions, the changes observed in typical cases, and leave out 
as much as possible theories, varieties and rarities. It is an 
easy matter to fill into the framework of positive knowledge all 
the possibilities and controversies, and it will by no means be 
a dogmatic teaching, because we may as well state here that there 
is no statement in medicine so positive that it may not be given 
up if a subsequent discovery is made. These facts must be clearly 
understood if we do not wish to be disappointed in our studies, 
for if we expect types of disease and types of pathologic condi- 
tions in nature we shall be very much disappointed. In our 
teachings, however, we must present such types which represent 
the majority of cases, leaving plenty of space for varieties within 
each type. For the student who has no knowledge of this science 
it is best to first impress such types upon his mind, and it becomes 
then an easy matter for him to group around this type different 
varieties of the typical condition and to explain the individual 
difi:erences, if he refers in his comparisons to the type learned 
at first. 

Anatomy and its auxiliary branches will teach you the normal 
conditions of form and structure; physiology, the functions of 
the parts and organs of the body in health; pathology comprises 
the teachings of changes in structure, form and function caused 
by disease. 

What is DISEASE? Disease is the condition of the body in 
which the functions are performed in an abnormal manner; 
this is, in most of the cases, combined with an abnormal state 
of the body. The functions of the body are many; some are of 
a nature which one may distinguish by his senses; we call these 
OBJECTIVE, others which are perceptible only to the individual ; 

4 



Besides tlicsc four li(';i(liii,^s of cliMnoos rroiii norinai to dis- 
eased eojiditions, we have eoiioenital differences from the normal, 
called AiixoK'MAi.iTiEs. An\- disease may be classified witliin this 
IVaiiie, with tlie understanding that nature does not allow distinct 
i v|)cs, as alluded to in our introduction. A pa t lioloii ic cniidilion 
may at the same; tijne belong to t^vo or three or all groups (jI this 
division, 

GROUP I. 
ANOMALIES OF CIRCULATION. 

Under the inthienee of ti-igiit the face blanches, but this local 
lack of circulation is not a disease; it passes away witli the dis- 
appearance of tlie impulse. But if the face remains blanched for 
some time — days or weeks — we speak of a pathologic lack of 
circulation, or anemia of tlie face. Under the influence of excite- 
ment the face flushes, but this flush disappears very soon. If 
the face remains red beyond limit of time and space — if it be 
burning hot on account of increase of circulation, enlarged ves- 
sels, etc. — we speak of hyperemia or euythemia. With other 
words, circulation may change within the limits of normal, but 
if these differences pa.ss beyond such limits, that is, persist longer 
than the physiological iminilse, or occur without such pliysiolog- 
ical impulse, then the diseased condition, anemia or liyperemia, 
is produced. 

These changes of circulation are: 

1. Local Hyperemia. It means that the circulation of a 
part of the body is increased beyond the physiological limit. It 
may be (a) active, (b) passive. 

(a) Active hyperemia (fluxion) , which is, as a rule, not a 
lasting condition, consists of an abnormal dilatation of blood vessels 
due to a nervous influence upon the muscles in the blood vessel 
walls. Its symptoms are increased redness and turgescence (hard- 
ness and stiffness) of the tissues. If it has been lasting for 
some time, the blood vessels may remain dilated. The result 
will then be increase of fluid between the tissue spaces and often 
increase of the size of the tissue cells. After death, hyperemia 
may leave no signs except this increase in cellular elements. 

(b) Passive Hyperemia is due to partial or total obstruction 
to the flow of blood through the veins (stasis) ; its signs are bluish 
discoloration and turgescence of th^ parts, Its cgnsequerices, if 

10 



lasting for some time^ are the same as in active hyperemia;, but 
there is more tendency to the formation of edema (which means 
an increase of serum between the cells and within the same). 
Active hyperemia permits of more nourishment to the tissues 
through its increased flow of blood; passive hyperemia reduces 
it by the slowing up of the flow. In extreme cases, however, both 
conditions may endanger the life of the cellular elements and lead 
to death of the same (necrosis). 

2. Local Anemia (ischemia) is the decrease of the blood 
supply to a part. It may be due to general lack of blood in the 
body or to an obstruction of the supply. This latter may be 
caused by compression or obstruction of the arterial blood supply 
or the nervous influence upon the muscles in the blood vessel 
walls. If it be lasting for a time, anemia endangers the life of the 
tissue cells and may lead to necrosis. Its signs are loss of color 
and flabby condition of the tissues. 

HEMOEEHAGE. 

Hemorrhage is the extravasation of blood. Under normal 
conditions blood is always confined to the vessels. We speak 
of hemorrhage if through some cause the blood has left the vessel. 
It may be: 

1. Arterial. 

2. Venous. 

3. Capillary. 

4. Parenchymatous. 

According to its size and extent we may divide hemorrhage: 
(1) Point-like, or ecchymosis; (2) suffusions, if they are 
larger and less defined; (3) hematoma, if they are tumor-like 
accumulations and clots; (4) hemorrhagic infarcts, if the 
hemorrhage extends between the cells of the tissue of the organ. 
If a hemorrhage takes place from one organ into a cavity, or out- 
side of the body, it is called by a specific name, usually indicating 
the source; for instance, epistaxis, bleeding from the nose; 
hemoptoe, bleediniT from the lunajs : iie:\iatemesis, from the 
stomach; metrorrhagia, bleeding from the uterus; hematuria, 
from the urinary organs ; hematometra, bleeding into the uterus ; 
HEMARTHROS, bleeding into the joints; piematocele, info the 

12 



tunica vaginalis testis : hemothokax^ bleeding- into the pleural 
cavity ; hemopericardium, bleeding into the pericardium. 

The cause of hemorrhage may be threefold: (1) A rupture 
of the wall of the blood vessel by an injury; (2) by changes in 
the wall lessening the resistance offered to the force of the blood 
current, often produced by regressive changes^ which will be dis- 
cussed later; (3) in rare instances to nervous influences^ as in 
vicarious bleeding; for example^ bleeding into the conjunctiva or 
skin instead of normal menstruation. 

THKOMBOSIS AND EMBOLISM. 

Thrombosis is the formation of a clot within the blood vessel. 
Under normal conditions blood is always liquid within the vessel 
wall. If, however, the circulation is weakened to such a degree 
that the flow of blood is retarded to an extreme, or cut off alto- 
gether, or if the blood vessel Avail undergoes regressive changes, 
so that they do not permit the sliding along of the blood column, 
or if the blood is changed in its constituent part, it coagulates 
and obstructs partially or totally the lumen of the vessel. Such 
a clot is called a thrombus. It is composed of blood corpuscles 
and fibrin, but may undergo a gTeat many changes. It may form 
a connective tissue (organized thrombus), or melt through de- 
generation. If a part of this clot is carried on with the circulation 
it may find its way into a small blood vessel, where it obstructs 
the circulation. The clot itself is called an embolus, the process 
EMBOLISM. The signs of thrombosis are those of loss of circula- 
tion in the parts depending upon those vessels, and the results 
are those described in passive hyperemia and local anemia. The 
embolus may be aseptic or infected with microorganisms (septic 
embolism) . 

Upon this differentiation hinge a great many possibilities. 
The formation of clots charged with streptococci, then embo- 
lism, will spread the process, and thus cause many local processes 
of infection. This is often the way infective diseases are caused 
through the body. 

ANOMALIES OF LYMPHATIC CIECULATION. 

The lymphatic circulation is dependent upon the blood cir- 
culation; every increase of blood to the vessels is followed by 

14 



a like increase of lymph within the lymphatic vessels and between 
the cells of the part which is affected. This increase of serum 
between the cells is called edema or hydrops. If it is present 
in the exposed parts of the body, the skin, the name anasarca is 
used. Within the abdominal cavity it is called ascites. It con- 
tains the same elements as the lymph. Besides these clianges in 
circulation there may be other causes for the development of 
edema. We distinguish three kinds of edema: (1) Edema 
through stasis (hyperemia, active and passive) ; (2) inflammatory 
edema (changes in blood vessel walls; increased permeability of 
the cells composing the blood vessel walls often tends to induce 
the formation of edema) ; (3) hydremic edema, due to excess of 
the amount of water in the blood, with simultaneous lack of 
albuminous matter. Such conditions exist in individuals run 
down by wasting diseases, as cancer, long-standing suppurations 
(cachexia), etc. 

LYMPHOEEHAGIA. 

Ltmphorrhagia is a process analogous to hemorrhage. It 
consists in the extravasation of lymph from an injured lymph 
vessel. Its causes are similar to those of hemorrhage. The per- 
sistence of such a flow of lymph from the body produces a 
LYMPH-FISTULA. A flow from a lymphorrhagia may lead to the 
filling of a body cavity with lymph, viz. : Peritoneum, called 
LYMPH-AsciTES, or into the thorax, called lympho-thorax. 

GROUP II. 

REGRESSIVE AND PROGRESSIVE CHANGES 
A. REGRESSIVE CHANGES. 

We understand by regressive change all those possibilities 
of transformation of a well-developed and organized protoplasm, 
as we find it in the cells of the normal body, into tissue of less 
vitality, or into material of lower physiological value. They 
range from a slight deterioration to the partial or total death 
of the cell material and its results. 

1. Atrophy. As the simplest change in a retrograde di- 
rection should be placed "aplasia, hypoplasia, or simple 
ATROPHY. The cell is anatomically of the same construction as 
in the ideal condition, but smaller in size and consequently of 
lower functional value. The causes for this backward step are 

16 



poor nutrition or mechanical difficulties (peessure atrophy)^ 
or an inactivity or neurotic condition (trophoneurosis). This 
latter is very interesting, showing that the growth of tissue is 
regulated hy a nervous influence. As examples may he cited the 
atrophy of the old age from poorer nourishment, all tissue cells 
being affected, or the atrophy from the mechanical pressure of a 
tumor, or, finally, the atrophy of a paralyzed limb. 

2. The slightest change in the cell is cloudy swelling or 
granular degeneration, and may be only temporary. It often 
happens during fever diseases in which the protoplasm of the 
cells become disintegrated. The change is microscopically 
shown by their change of color and consistency (the organs ap- 
pear like cooked), and macroscopically by the appearance of gran- 
ules within the cells, which are easily stained by the anilin dyes 
and give the appearance of cocci within the cells. 

3. Hydropic Degeneration. If the cells undergo a change 
slightly greater than granular degeneration, they show accumu- 
lation of liquid within the cell bodies (hydrops of the cell). 
These accumulations of liquids appear as empty, round spaces 
within the cell body when seen under the microscope, and the 
organs thus affected are softer than normally. 

4. Fatty Degeneration. The formation of smaller or 
larger fat globules within the cells, in wiiich normally no fat is 
found, is a degeneration. Fat is easily recognized under the mi- 
croscope by its lustre (dark hue), and the characteristic test 
with osmic acid, which stains it black. Fatty degenerations are 
mainly caused by a lessened oxidation of the protoplasm, that is, 
less or poorer blood supply, and its result is a lower functional 
value. 

Fat may crystallize within the cells in various forms, as 
rhomboid crystals or plates or groups of needles (cholesterin) . 

An accumulation of larger amounts of fat may lead to the 
formation of oil (yellow), or, if mixed with blood of reddish or 
even a greenish color (oil cysts). With the naked eye the 
organs thus affected appear yellowish, are more friable, and show 
fatty substances, even oil drops upon the freshly broken surface. 

5. Mucoid and Colloid Degeneration. Mucus and the 
aggregate condition of glue (colla) are changes which are peculiar 
to some cells of the body in mucous membranes under physiolog- 

18 



ical conditions (gol)let cells) ; however, under pathologic condi- 
ditions not only goblet cells, Init any kind of cell transforms 
into mucoid masses; especially tumor cells • are predisposed to 
such mucoid and colloid degenerations. The difference between 
mucoid and colloid masses is their chemical reaction. If mucus 
is treated with acetic acid it coagulates, and the cpagulum can not 
be dissolved by adding acid; alcohol also coagTilates it, l)ut water 
added to it will swell it. These reactions are not applicable to 
colloid cells. The cells in l)oth instances appear tilled witli a 
jelly-like mass, which may be colored green or yellow. 

6. Hyaline Degeneration. Hyaline degeneration is the 
transformation of the cells into a substance which does not show 
any texture, but is transparent, and accumulates in irregular 
masses within the cells. It appears within the vessel walls, the 
connective tissue, brain and kidneys, and its origin is obscure. 
It seems that the cells are first swelled up by a liquid which coag- 
ulates and forms the hyaline masses. Blood vessels may he easily 
occluded. 

7. Amyloid Degeneration. Amyloid degeneration is the 
transformation of the protoplasm into an allmminous body of a 
glairy, albuminous appearance, transparent, which gives a char- 
acteristic reaction toward iodine and various anilin dyes. Hy- 
aline degeneration is very similar, but lacks this reaction. Macro- 
scopically, the tissues appear like sago or wood, and if treated with 
methyl or anilin violet they appear ruby red, while the healtliv 
tissue appears blue or dark violet. If treated with a watery or 
potassium iodide solution of iodine, amyloid is brown, normal 
tissue yellow. 

This characteristic reaction enables us to make the correct 
diagnosis of this change; it is caused by poor nutrition, char- 
acteristic of cachectic conditions as they follow suppurations of 
long standing; tuberculosis, syphilis, etc., while carcinoma rarely 
causes such a change. 

8. Pigmentation introduces a degenerative process inas- 
much as all foreign substances which are physiologically inactive 
must reduce the vitality of a cell. Such pigmentation may be 
formed in the body or may enter it from without. Blood is the 
most common source of pigment (hemin, hematin, hemoglo- 
bin). It may form darker or brighter masses of crystals or cry^ 

20 



allized formations within the cells, or they may transform into 
melanotic masses, as we find them in some tumors (melanosar- 
coma) . 

Bile is another source of pigmentation. Icterus is the pig- 
mentation of the tissues caused by the absorption of bile; pigmen- 
tation may be caused by foreign bodies like silver (argyeia), 
copper, iron, nickel, and other metals. 

9. Chalky Degeneration is a higher degree of regressive 
change by deposits of foreign material within the cells and sub- 
sequent lowering of function is their impregnation with salts, viz. : 
The chalk from the calcium salts as it is found in amorphous 
masses and crystals, especially in the cells of old individuals, in 
the blood vessels (arterio-sclerosis), or in the tumors 
(fibroids). Uric acid salts are often deposited in cells in dis- 
ease (arthritis urica). 

10. Osseous Degeneration. The osseous deposit of cal- 
cium salts with the formation of bone is a degeneration of com- 
mon occurrence in some organs (lungs) where cartilage or con- 
nective tissue is present, but even in organs where cartilage or 
bone is not present normally. 

11. ^^ecrosis. We may define as the last degree of degen- 
eration the change which transforms the cells to such an extent 
that they die; this regressive condition is called the cell-death or 
NECROSIS. If the cell has been disturbed in its vitality by me- 
chanical, chemical or thermal influences, or by its lack of nutri- 
tion (local asphyxia), the result is a death or necrosis of the 
same. A slight impairment of the cell will lead perhaps through 
a number of stages of regressive changes before the cell dies; a 
rapid injury may lead to a sudden death, and between both the 
slow course (necrobiosis) is a hovering between life and death. 
Sometimes the cells recuperate. In other instances they are 
doomed to destruction. This local death is, of course, of different 
value, according to the cells affected. While in the muscle 
a local necrosis is of no great significance, in the brain a minute 
necrosis may lead to the gravest possibility. The final result of 
all regressive changes offers a great many possible outcomes. 

While some changes are passing, and the tissues recuperate, 
in other instances it leads from bad to worse, and the fate is 
necrosis. The results of necrosis may be : 

22 



1. The removal of dead tissue b}^ exfoliation or absorption 
and its replacement b}- normal tissue (kegeneration) . 

2. An exfoliation of the necrosed tissue and replacement by 
a new tissne of scar formation. 

3. Partial absorption of necrotic tissne and chalky infiltra- 
tion of the remainder, with the formation of a capsule around it 
(encystment). 

4. The transformation into a liquid with its surrounding 
capsule. This latter condition is very common, and especially 
peculiar to some organs of the body. The formation of cysts 
with distinct walls is usually the result of such local necrosis. 
The fluid is of a different character, according to the tissue from 
which it has been formed. The color and consistency of the fluid 
of the cyst depends upon the blood supply to the part previous 
to the necrosis. 

The walls of the cyst are usually the result of a reactive in- 
flammation in the neighborhood of the necrosed portion. When 
the inflammatory cells have formed out to connective tissue, a 
solid wall is formed. 

. FORMS OF NECEOSIS. 

ISTecrosed cells dissolve in difi^erent manner. Thus we dis- 
tinguish the difterent forms of necrosis: 

1. Coagulatiois' iSTecrosis. The dead cells form a fibrinous, 
granular or homogenous mass, with a loss of contour and structure 
of the organ. 

2. CaseatiojsT' or Cheesy Dege^^eration is the transforma- 
tion of tissue into soft consistency, partly fatty, parti)- albuminous, 
white or yellowish, often hardened. 

3. Liquefaction, or transformation of the cells into fluid. 

4. MuMMiFACTiON, or death of tissues, with death of the 
cells, transfusion of the coloring matter of the blood, and conse- 
quent dark discoloration (dry gangrene). 

5. Moist Oangrene,, or the transformation of tissue into 
easily friable, livid, structureless masses, decomposing with the 
formation of foul gases. 

B. PEOGEESSIVE CHANGES'. 
Progressive changes of tissues or whole organs are such which 
show an increase in size or number of cells when compared with the 

24 



normal. The increase in number is called hyperplasia. The in- 
crease in size is called hypertrophy. Both conditions are path- 
ologic changes, though they do not always signify a deterioration 
or lower functional value of tissues or organs. The cause is us- 
ually a nutritive irritation, or loss of the resistance to growth of 
organs or cells. The organs or cells are, as a rule, under certain 
mechanical relations which allow only a certain size or growth, 
but if the resistance or obstacles are removed, then such cells or 
organs may proliferate in size or number. For example, if the 
valves of the heart fail to act promptly, the muscle of the heart 
has to perform more work in order to keep the same amount of 
blood in circulation. This increase of work will cause the muscle 
to become larger, more cells will be developed, and the volume of 
the muscle as well as the number of cells composing it will in- 
crease. In the same way the muscular apj^aratus increases within 
the bladder if a stricture of the urethra prevents the normal flow 
of urine, and the bladder has to perform more work. 

Another kind of increase in volume is represented in the 
hypertrophy of the prostatic gland in old men, where the elements 
of the prostate increase in number and size, but also the inter- 
stitial elements of connective tissue as the result of 
chemical chano-es, irritation and other causes. The diaoriosis of 
these progressive changes is easily made l)y comparisons of the 
organs. The physiological value may be decreased if, as is the 
rule, in the ultimate stage the hypertrophic tissue undergoes de- 
generative changes. 

In connection with these (pathologic) changes there must be 
considered certain physiologic processes of growth and develop- 
ment of cell and tissues called by the collective name of regenera- 
tion or CELL repair. 

EEGENEEATIO^s^ 

If tissues have been destroyed by an injury of any kind, there 
are three possible consequences which may follow, viz. : Necrosis, 
or scar formation, or regeneration. 

1. Eegeneration of Epithelium!. Epithelium is a highly 
organized cell, whether in epidermis or mucous membrane. When 
destroyed, ne^v epithelium may be formed by the process known 
as karyokinesis. Only when all the epithelium is destroyed is 

26 



its place taken b}^ connective tissue. As long as small remnants 
of epithelium (cells witli nuclei) remain, new cells can grow 
from these^ but the character of the epithelium must not always 
remain the same, so that, for instance, cuboid or cylindroid epi- 
thelium may be replaced by the pavement variety. Epithelial 
cells may retain their life for some time, even when separated 
from thfc body, so that they may be transplanted. This possibility 
is proven by grafting of skin or mucous membrane. The process 
of karyokinesis is characterized by the gradual development of 
two cell bodies from one through stages as shown by the illus- 
tration. 

2. Blood Vessel Eegeneration. Blood vessels are apt to 
form anew when destroyed, and their formation is one of the most 
important factors in the process of tissue restoration. They de- 
velop as solid sprouts from the cells of the capillary 
vessels; the sprouts join in the shape of arched boughs; there 
arches gradually become hollow tubes, and open into the capilla- 
ries, thus allowing the entrance of blood corpuscles, and the cir- 
culation is established. The sprouts consist of cellular elements, 
but when they gradually develop into walled tubes a layer of con- 
nective tissue and the lining of endothelium forms in them, thus 
representing all the constituents of a blood vessel. 

3. Eegeneration of Cot^nective Tissue. All the higher 
forms of connective tissue, as bone, cartilage, periosteum, lymph 
glands, fat tissue, etc., may regenerate also by the process of 
karyokinesis, but very often tissue of an indistinct, non-differ- 
entiated character, as observed in the embryonal period through- 
out, takes the place of the higher developed connective tissue. 
This is called the germinal tissue, and forms the scar as a re- 
sult of an injury. 

4. Muscle Tissue Regeneration. Muscle Tissue regenera- 
tion develops in the same manner after an injury as epithelium, 
viz. : By karyokinesis and cell division, but often germinal tissue 
takes the place of muscle cells, resulting in a scar, especially when 
a great deal of the muscle has been destroyed. 

5. Nerve Regeneration, ^^'erve cells and fibers may be re- 
stored after injury. Fine filaments form sprouts (intact nerve 
fibers), and by gradual development of the nerve sheath about 
these filaments matured nerves are formed. Such a restoration of 



28 



nerve filaments may take place even across a breach of the injured 
nerve if there is only some means of connecting the broken nerve, 
so that a thread of catgut or silk, or a decalcified bone tube, will 
afford a support for new-forming filaments. If the. nerve, how- 
ever, is not directly connected, then these new-formed filaments 
often develop irregular, bulbous growths (see neuroma). 

If a nerve has been cut, for instance, then that part of the 
nerve which is still in connection with the central nervous system 
throws out new fibers, which grow alongside the peripheral and 
dead, old fibers, and gradually replace the same, while the distal 
part of the cut nerve gradually disappears by absorption. 

GROUP III. 
INFLAMMATIONS. 

Inflammations form a large group of pathologic changes. 
We call inflammation the combination of a number of symptoms, 
objective and subjective. We observe in inflammation some signs 
which are lost in the pathologic specimen. We speak of five car- 
dinal symptoms of inflammation, viz.: (1) Redness (rubor); 
(2) swelling (tumor) ; (3) pain (dolor) ; (4) heat (calor), and 
(5) the impaired function; but these five S3^mptoms are not always 
necessarily present to form the pathologic change of inflammation, 
tion. 

The cause for inflammation is a certain irritation of the tis- 
sues which is followed by changes in the circulation. These ex- 
plain the cardinal symptoms. As a result of the irritation, the 
blood vessels of the inflamed part become dilated, and more blood 
enters the vessels. The current, however, is decreased, the white 
blood corpuscles and some red cells leave through preexisting 
openings (stomata) between the cells and the blood vessel wall, 
and fill the spaces between the cells. This process is called 
LEUCOCYTE-INFILTRATION. Scrum also Spreads through the tissue 
cells and forms an exudate (edema). 

The results of these changes are manifold. Thev depend 
upon what kind of exudate is formed. These exudates may be 
solid, _ semi-solid, or even liquid, according to the different ele- 
ments composing them. 

We distinguish (1) the serous or sero-fibrinous exudate. 
It consists of serum with flakes of fibrin, leucocytes, and 'sparingly 

30 



of red cells. If coming from the surface of a mucous membrane, 
this discharge is called CATAKiiHAL discharge. It often con- 
tains mucus from the goblet cells. (3) The croupous exudate 
consists of coagulated serum with a large amount of fibrin, it 
presents a white or grayish membrane. (3) The purulent ex- 
udate is an accumulation of large quantities of white blood cells, 
a small amount of fibrin, and debris of tissue. If this secretion be 
upon the surface of a mucous membrane, we speak of it as a 
purulent catarrh. Any of these exudates may be tinged with 
Ijlood, and are then classified as hemorrhagic. 

THE EESULTS OF INFLAMMATION. 

There are several possibilities as consequences of inflamma- 
tion : ' . 

1. All signs and symptoms may disappear, exudates may be 
absorbed, healing or restitution to the former state of health may 
be the result (restitutio ad integrum). 

2. At the site of the inflamed part there may develop a 
new tissue of a character known as germinal or embryonal 
(granulation) tissue, with a large amount of newly-formed blood 
vessels. This may be gradually replaced by a scar, or may con- 
tinually keep on forming and decaying, thus resulting in chronic 
(lasting) granulation with suppuration. Large amounts of such 
granulation tissue are called granuloma. If the pus finds its way 
outward, it passes through a canal lined with granulation tissue 
(fistula). 

If the granulation is formed on the surface of a mucous 
membrane or epidermis, an ulcer is established. 

3. If the inflammation has been such as to interfere with 
the nutrition of the tissue, this tissue may die or become necrosed. 

The living tissue tries to get rid of such necrosed portions, 
a process called sequestration or demarkation^ the dead por- 
tion being called the sequestrum. This term is especially applied 
to dead bone. 

FORMS OF INFLAMMATION. 
The inflammations which interest the surgeon may be classi- 
fied into (1) ACUTE, and (2) chronic. The term acute signifies 
that the disease appears suddenly, and after a short, typical course 
terminates in recovery or death of the tissue affected, or the in- 

32 



dividual. Some of these diseases may acquire tlie characteristics 
of the second group, and become chronic. The process of in- 
flammation in its simplest form is shown in certain conditions 
related to injuries of the body and its cells, a process called wound 
healing, and it will therefore be described in connection with this 
chapter. 

WOUND HEALINa. 
A WOUND is a disruption of tissue by force. Any kind of 
tissue may be torn or lacerated, but not every laceration is a 
wound. If, for instance, a process of softening by some sort of 
pathologic condition disrupts or tears the tissue apart, it will not 
be called a wound. If a knife be plunged into tissue, it will sepa- 
rate the cells of the tissue. This will be a traumatic disruption, 
or wound. 

Violence may cause injur}^, either by instruments or mechan- 
ical means of other form, as pressure. The instruments may be 
sharp or blunt-pointed. Blunt instruments, like a hammer or 
stick, will produce a different kind of wound than a knife. We 
have, therefore, different kinds of wounds, depending on their 
method of production. A pointed instrument, as a needle, will 
produce a punctured wound. A knife will produce an incised 
sharp wound; a hammer, a lacerated wound; continued pressure, 
an irregular, lacerated wound. We call a wound lacerated when it 
has irregular borders, with some portions of living tissue, some of 
half living or dead tissue, and still other portions of dead tissue 
adhering to the borders. The latter is called necrotic tissue. 

The results of wounds may differ. Wounds of the tissues 
may or may not heal. This depends on different conditions, which 
are within or without the individual. 

Wounds can be produced upon any kind of tissue. We can 
have wounds of the skin, muscle, bones, fat, or of organs, as the 
eye, or ear, wounds of the nerves, brain, etc. The conditions, as 
stated, within or without the individual, will determine the result 
of the wounds. If an absolutely healthy individual is lacerated 
or wounded, this wound will have an entirely different course from 
that which it would have if the individual who was struck by that 
violence were diseased or ill. If a wound is produced on a patient 
suffering from chronic ailments, such wounds are not healthy. 
This would be a condition within the individual. 



34 



Wounds also take a different course when the violence hat; 
been of a pure nature from that which they take when the violence 
has been at the same time accompanied by the invasion of some 
foreign material of a parasitic nature, or a chemical nature, which 
is dangerous for the individual. The results, therefore, are varied. 

Nature tries, when a wound is produced, to restore conditions 
to the normal or to the previous state. We call this tendency of 
nature restoration to the integral state, or, in Latin, "kestitutio 
AD INTEGRUM.'" This tendency of nature to restoration to the 
integral state is a general law. 

If nature can reproduce the delicate structure that has been 
destroyed, it is an ideal repair. If it can not, it replaces the 
wounded tissue with tissue which is very resistant, -scar tissue. 
As an example of wound-healing, the skin furnishes the best 
illustration. 

The skin has a structure composed mostly of two layers : 
A layer consisting of epithelium, and a layer of connective tissue. 
The epithelial cells which cover the surface are of different kinds 
— large cells at the bottom, with large nuclei, the cells becoming 
flatter as we near the surface, and, finally, on the surface flat cells 
that have no nuclei at all, being only dried out cells which we re- 
move from the surface every day by washing and rubbing against 
foreign bodies. If we look at the skin under the loupe, we can see 
the scaling-ofi' of the cells. 

Under the epithelial layer lies a connective tissue, a layer 
of elastic and other fibers, which allows a motion of the skin. 
This more or less elastic tissue contains the blood vessels in the 
form of loops, which carry nutrition to the surface. It is broken 
here and there by a hair follicle or a gland, the last-named carry- 
ing oil to the surface of the skin, keeping it lubricated. There are 
also glands which carry ofl: the sweat, "sudoriferous"' glands. 

If this skin has been wounded by a knife being plunged in, 
the signs will be: (1) Disruption. The result of that incision, 
even though the knife be very sharp, is found under the microscope 
to be similar to that which would follow the use of a saw, only with 
the naked eye it appears to be a sharply cut wound, while under 
the microscope or loupe it would appear to be a very irregular 
wound. The sharp, incised wound and the torn wound differ 
only in a degree of roughness. The cells are caught by the sharp 

36 



edges of the kuiJe and torn out and apart; nome of tlieiii are torn 
out of tlieir connections, some are torn jjiidvvay into parts, and 
sojue are simply touched. 

The first symptom we have as a result of tiie wound is a 
GAPING of the borders, which recede to either side. Why will they 
recede? There are very line, small bundles of muscles in the 
skin, which njay be seen to act, even under the IjiUuences of 
changes in temperature, if the arm be exposed to the cold, little 
hilly portions will form on the skin, so-called "goose-skin.'^ The 
infiiicnce of fright will also cause goose-skin to form. This is 
nothing but the contraction of some of the muscles in the neigh- 
Ijorhood of the hair follicles. The muscles push the hair out of 
tlie surface, and a hilly portion forms where there was a flat por- 
tion before. Such action of the muscles and elastic fibers will 
separate the borders of the wound. This separation will be more 
pronounced in some directions than in others. This direction of 
gaping is very important f(jr tlie surgeon. If we make an incision 
in tlie skin, we know that some directions of such an incision 
allow of more gaping of the wound than others; for example, 
if the neck be incised transversely, there will be a wide gaping 
of the borders; while if incised longitudinally along the axis it 
will result in less gaping. 

(2) Hemorrhage. The next result of the wound will be 
ho'morrhage. 'I'he space that has been created by the gap will be 
fillc'd with the contents of the lacerated jjoi'tion- of the tissues, 
if a blood vessel, one of the capillaries ha~ been cut across, tlie 
result is that the lilood. vessel being open, the hlood forced by the 
action of the heart escapes into the surrounding tissues. If thi; 
incision happens to cut a larger vessel, ;in nil* ry, there will be a 
percejjtiljle -cpiirting of the hlood. If ;i vein, thfiiv; uill 1h; a 
steady flow of blood. Out of a capillary loop, there will he a 
ilow, not vei'y strong, but sufficiently so to form a crust, if it 
dries out on the surface of the wound, Suppono tli;it tho incision 
would have gone only below the upper layer of th(i capillary v(<- 
sels, then this entire gap would be filled with hlood, which would 
keep on flowing as long as tlie force fioni Ix lou i- erpud to the 
forc(^ above. What force prevents ii from flowing out constantly? 
It comes to tlie surface. It is reji(liin;i a different temperature, 
usually colder than on the inside. 'I'be water that is contained 

38 



in the blood will evaporate, the blood will become thicker, there 
will be a tendency to the formation of a coagulum (clot) 
on the surface of this gaping wound. Up to this moment all 
wounds would be alike^ but from the time the clot forms the re- 
sults ma}^ be entirely different. 
(3) Eepair, 

A. WOUND HEALING BY PRIMARY UNION. 

Take, first, as example, the most simple, the ideal, process of 
wound healing. The formation of the clot may take an hour, 
perhaps only a minute, sometimes much longer. That depends on 
the individual. There are some individuals who are hemophilic 
(bleeders). They have a very slight tendency to clot-formation 
in the blood. The greater number of people, however, have a good 
tendency to clot formation, and after this gap has been filled and 
the surface covered with a clot, there begins a process which we 
know as "repair.^^ 

(a) Karyokinesis. Nature tries to replace everything a? 
it has been before. Epithelial cells, as a rule, are very delicate 
structures, and nature will not be able to replace these very fine, 
delicate structures. Under very favorable conditions, however, 
it may ; but if the wound has been of some extent and a great many 
of these cells have been destroyed, nature is not able to repair them, 
consequently we will have, as the result of most wounds, a scar. 
If we have an ideal repair, then we have none, or very slight, 
scar. 

What becomes of these cells on the border of the wound? 

Some of them are lacerated to a greater extent than others. 
They will be dying off altogether. The portion of the cell which 
has been severed from contact with the living will die off. Other 
cells will fall out, because they are torn, and gradually a line of 
separation of the living and dead will be formed. • 

While some of these cells will, as we have seen, fall out, 
others will try to multiply. The process is known as karyoki- 
nesis. The result is the formation of two cells out of the previous 
one. This process goes on with the halves again, and so we can 
have after a time four cells out of two. Such a process takes place 
on the borders of a wound, and we have after a while some newly- 
formed cells. 



40 



(b) Dilatation of Blood Vessels. In the meantime, something 
happens in the neighborhood of this wound which we can call by 
the general term of blood changes. The blood vessels are irritated 
in such a manner that they dilate immediately after the injury. 
If you cut yourself on the skin and watch that little cut carefully 
after the blood has stopped flowing, you will see that the borders 
of that cut after a while are red, even though no infection be 
present. This redness is due to the enlargement of the vessels, 
and to the greater filling of their caliber with blood. 

(c) Infiltration. The blood consists of red and white blood 
corpuscles. The white cells are much less in number than the red. 
The red cells remain inside of the vessel as long as the walls of the 
vessel are intact. Once in a while a red corpuscle can slip out of 
the circulation, but, as a rule, it does not. On the other hand, 
the white corpuscles may slip out of the blood vessel, having a ten- 
dency to escape through the very small preexistent holes in tho 
wall of the vessel. Every blood vessel is lined with large cells, 
and between the single cells there are tiny openings,' mouth-like 
(stomata), through which the circulation rids itself of the mat- 
ter which it supplies as nutrition to the cells surrounding it, and 
through those little openings slip the white blood corpuscles into 
the tissues surrounding that portion of the vessel. Thus we find 
white cells outside of the vessel walls. These white blood cells 
have been called scavengers, because they tend to enwrap with their 
body everything that does not belong to the circulation, and carry 
it off. In that sense they are the scavengers of the body; they 
take up every foreign material they can encompass and carr\' it 
back into the circulation, or outward, if the}^ can. So, in a case of 
wounding, these white blood corpuscles spread within the tissue. 
We call this spreading "infiltration.^^ We have, therefore, as the 
next symptom or sign of wound healing or repair, the infiltration 
of the tissues. 

In the wound the scavengers will have a great deal to do ; 
they will come and carry off the dead cells. For example, a dead 
cell which has been broken by the cut is taken up by the white 
cell, which forms a sort of clasp about it, breaks this dead cell 
up into smaller particles, and gradually encloses a particle with 
its protoplasm, and, moving along toward the current of circula- 
tion, carries that little dead cell back into the l3^mph circula- 

42 



tion. Or, if it happens to be near the gap of the wound, it carries 
It outside. Most of the ideal wounds heal without such throwing 
out of cells upon the outside. But large wounds discharge great 
quantities of such white blood corpuscles outward. In the ideal 
state, however, we have such white blood cells carrj^ing the dead 
material into the system b}' the lymph circulation, and from the 
lymph into the blood circulation. After this has gone on for some 
time, we have in place of the dead cells only white blood cor- 
puscles, and repaired new cells. 

(d) Formation of Scar Tissue. The white blood corpus- 
cles have, however, another purpose. Some of them are trans- 
formed into connective tissue cells. If, for instance, this white 
blood corpuscle remains at the point where nature has not been 
able to repair a cell, it is transformed into a fixed or connective 
tissue cell. It becomes oblong, acquires a cell nucleus, becomes 
more and more slender, the nucleus disappears, and, finally, as a 
result of the transformation, there remains a fiber. After all 
the dead tissue has been removed and repair has taken place, the 
site of the wound is filled with a tissue composed of fibers, which 
is called a scar. There are other explanations of the formation 
of the fixed germinal cells, but this is the most accepted. 

B. WOUXD HEALIXG BY SECONDAEY UMOX. 

The healing of a wound in an ideal manner is called by it? 
technical term, wound healing by primary union. Wound healing 
by primary union is very common, but it is not the rule. Obstacles 
of various forms prevent such primary union. Among these ob- 
stacles are some which are of importance, because they can be 
eliminated, and primary union can be obtained if such obstacles 
be kept out. 

OBSTACLES TO PRIMAEY UNIO^sT. 

1. First of all is the non-adaptation of the wound borders 
or the gaping. If a wound is to heal by primary union, or in an 
ideal manner, the borders of the wound have to be exactly 
adapted. It is well known to every surgeon that if he were to 
suture or close wounds in such a manner that the cut borders would 
not touch each other, but overlap, or that one would be higher than 
the other, or perhaps both be rolled i]i, he would never obtain pri- 
marv union. This ha? its reason in the fact that only tissues of 

44 



the same character will grow together with the least possible scar. 
Tissues of different character will either not grow together, or 
they will grow together with the formation of a scar. This applies 
not only to the skin, but also to the serous and mucous membranes. 
Wherever, for instance, we have mucous membrane touching con- 
nective tissue or bone, we have no primary union. There must be, 
therefore, an exact adaptation of corresponding wound borders. 

2. Such adaptation of the wound borders may, however, be 
prevented by the inclusion of a foreign body. For example, a 
portion of the weapon which was instrumental in making the 
wound may be broken off and retained in the wound, or a portion 
of dead tissue from the wound itself may be included within the 
wound, acting as an obstacle to primary union. That is the reason 
the surgeon washes the wound or allows the blood to wash out the 
foreign material. The layman knows that if he sucks the blood, 
or squeezes the blood, from the wound, he will have a better heal- 
ing tban if he leaves it alone. People do it as a routine, but the 
reason is that they remove from the wound all foreign material, 
which may act as an obstacle to primary union. 

3. This principle applies also to a third form of obstacle, 
and that is a foreign material which not only is a foreign body, 
but a parasite. This is what we call infectious material, or micro- 
organisms. 

Microorganisms are foreign material— the most dangerous 
form of foreign material preventing primary union, because they 
have the property or quality of multiplying, and doing this in an 
enormous numl^er and rapidly, so that from several individuals 
they may increase to several millions of individuals within a Yery 
short time, producing locally as well as distant from the place they 
enter very severe and deleterious effects. 

If it happens that the two borders of the wound can not 
touch each other, because there is, for instance, a foreign body in- 
terposed at one point, then there will be a different process, called 
the process by secondary union or process by granulation. This 
foreign body acts as a mechanical irritant, while a foreign body 
in the form of a microorganism acts both mechanically and chem- 
ically in producing inflammation. 

Pus. As the result of an inflammatory condition, we have 
again what we call inflammation of the tissue, viz., an infiltration 

46 



with leucocytes. White blood corpuscles leave the tissues in great 
numbers. They have in this case much easier work to do than in 
the case of primary union. They can surround the foreign body 
and lioat it outward. Througli their property of motion they crawl 
around that foreign bocly^ and leave the wound in quantities, pass- 
ing to the outer surface. One of the characteristics of secondary 
results of union is the discharge of liquid, which consists in large 
degree of white blood cells and a fluid, the serum of the blood. 
This discharge of liquid consisting of white blood corpuscles in 
large masses and serum has a yellow color, and the layman as 
well as the physician knows it under the name of pus. Pus is, 
therefore, nothing but an accumulation of white blood corpuscles 
and serum. As soon as the white blood corpuscles leave the tis- 
sues they lose their life and become disintegrated. Their proto- 
plasm is not nourished as well as on the inside of the body, and 
we find, therefore, in the course outward not only the living white 
corpuscle, but the corpuscle which is falling apart, consisting of 
granules of protoplasm. We find serum; some fibrin of the blood, 
and also some red cells in pus, because some of the blood vessels 
have allowed not only the white blood corpuscles to pass through, 
but some red ones. If we find many red corpuscles, the pus is 
reddish-yellow or pink, while if the red cells are small in amount 
the color is yellow. If many white cells are present, the pus is 
thick; if few are present, the pus is thin. 

Besides these characteristic ingredients of pus, we find dead 
tissue (debeis), which has been carried away with the white blood 
corpuscles. 

During the first few hours after an injury, the discharge is 
watery; there are ordinarily few white blood corpuscles present. 
But gradually the number of white blood corpuscles increases and 
the discharge becomes thicker. It loses more and more the red 
color of fresh bleeding, and gradually becomes 3"ellow, until 
finally after the second or third day it consists almost entirely 
of white corpuscles. One can imagine that those tissues being 
constantly washed by pus, the foreign body, if not too firmly 
wedged in, may be washed aw^ay, and leave the wound. 

Oranulation. In the meantime, however, changes take 
place within the blood vessels, and these changes have given the 
name to this formation of wound healing by "granulation.'^ 

48 



Tlie capillary vessel which has been injured during the 
wounding process will be obliterated altogether. This destruction 
takes place in such a manner that the blood within the vessel 
coagulates. Blood has this property: When it conies in contact 
with anything except the normal walls of the blood vessels, fibrin 
is formed, and a coagulum or clot is the result. Whenever blood 
comes to the surface, it does not remain liquid for any length of 
time; it soon forms a coagulum. That is due to the fact that 
some water of the blood is lost by evaporation; some fibrin is set 
free by a ferment through contact with air, thus forming a thick 
mesh-work in which the red corpuscles are . caught and a thick 
coagulum formed. The nearest blood vessel from which this 
obliterated vessel was fed shows a change of structure, in that 
manner that the cells of its wall begin to sprout. This process of 
sprouting continues until two such sprouting cells come in con- 
tact with each other. 

This has been observed under the microscope, very largely 
between the third and fourth days after the injury, sometimes 
even sooner. 

This connection between the two cells is in the form of an 
arch or bow. Between them are cells of the character described 
as germinal, formed from leucocytes, so that they can arch or 
bend across these cells. As soon as they have been connected 
with each other, they become hollow and form a tube, at first small, 
but gradually becoming larger and larger, finally becoming so 
large that it allows a blood cell to pass through; then a part of 
the blood circulation from the larger vessels in the neighborhood 
passes through this new canal, and we have as the result of the 
production of the sprout or bow a new blood vessel. These bows 
or arches of new circulation can form one on top of another. From 
this new sprout another cell forms and reaches across germinal 
tissue; then a second one, and so on. It organizes into a tube 
and the blood cells pass through it again. And so, one on top of 
the other, these arches form in rapid succession until the whole 
wound is filled with such bows of blood vessels of new formation. 
These new blood vessels filling rapidly with blood soon become 
of a reddish hue. 

If there is no obstacle to their growth, they form in such 
rapid succession that they very often overstep the boundary of the 

50 



wound and form large masses on its surface, a formation wliicli we 
call '^PEoun flesh'' or granuloma. Sometimes in the shape of 
tumors of quite a considerable size, they form over the borders of 
the wound, theii; nature being such that they always form bows, 
giving to the mass the aspect of granules, round, hilly elevations, 
as seen by the naked eye, and therefore they have been called 
granulations. They consist of nothing ])ut a very thin fihny wall 
of a blood vessel, through which the blood corpuscles pass, and 
germinal cells. They are extremely susceptible to injury, vulner- 
able to touch or pressure, so that they bleed very easily. There- 
fore, we have easy bleeding among newly-formed blood vessels. 
Granulations may be healthy or good, or they may be sickly of 
poor. When healthy, they have a deep pink or red color. If poor, 
their color is white or pale. This depends upon the amount of 
blood they contain, and on the health and thickness of the wall 
of which they are composed. 

This granulation does not go on perpetually, as a rule. 
Sometimes it oversteps the boundary, as stated, but usually it goes 
only so far as to till up the borders of the wound. When this is 
accomplished, the granulations have fulfilled their work, and then 
they cease growing and transform again. They become thinner: 
some of them disappear; the blood ceases to pass through them; 
instead of that, the cells within them — the germinal cells — be- 
come larger, sprout, and crush out the blood vessels, and so, as 
the final result, these cells within them form fibers which join 
and obliterate the vessels, and a "scar" is the result. This scar, 
however, is a different form of a scar from the one by primary 
union. First, it contains blood vessels, consequently it is very 
well supplied with nutrition, and such a scar has a tendency to 
return to the formation of granulations. Such a scar can be 
easily transformed into a wound again if it is disturbed, and such 
scars sometimes remain permanently supplied with blood vessels, 
so that they have fine lines or streaks of red during the balance 
of the individuates life. 

Epidermization. At the same time, another process takes 
place, that of the closure of the wound by overlapping of the 
borders of the epidermis. The borders of the epidermis also try 
to reach over these granulations, and when you observe such a 
wound in the process of healing by secondary union, you may see 

52 



how day by day the ring which forms around the wound grows 
smaller and how it becomes white; first, a reddish- white ; then 
paler and paler, even whiter than the surrounding skin, until it 
finally reaches over and closes, with the formation of a scar in the 
center over the whole wound. Not that the epidermis must fill 
out the entire gajo — the connective tissue remains between the 
two borders of the eqidermis. At that time the discharge ceases 
and the wound becomes dry. The last discharge which comes out 
of such wounds usually forms a crust on the surface, and is a 
sign that the wound has healed. 

Herein is an interesting phenomenon : That is, when the 
discharge becomes poor and disappears gradually, we often find 
a crust formed, but beneath the crust is to be found some pus, 
and while the wound is apparently healed, we still have some dis- 
charge, and if we remove the crust we have underneath the forma- 
tion of some pus. We must now allow the formation of a crust 
on granulating wounds until we are absolutely certain that there 
is no more discharge to follow, because if the discharge gathers 
underneath, it will destroy by its presence and decomposition 
some of the newly-formed blood vessels, and thus retard the 
wound healing process. 

WOUND INFECTIONS OE WOUND DISEASES. 

The infections are often the cause of secondary union, and 
wound diseases. We observe that some wounds heal, in the same 
individual, at one time nicely and without inflammation and 
formation of much scar tissue, while at other times the wounds 
have no tendency to heal, but, on the contrary, the tissues have 
a tendency to decay. If we seek the cause of this difference, we 
have to look for the little germs or microorganisms which are at 
the bottom of these changes. 

The knowledge of these conditions is not very old. Up to a 
few years ago, and within the memory of even the younger physi- 
cians, the knowledge of most of these changes was an imperfect 
one. We did not know why in one case the wounds healed well 
and in another not so well. Why, for instance, one man, when he 
cut his hand, would have a perfect union of the cut borders, while 
another individual, under the same circumstances apparently, when 

54 



he cut his hand would have a long, tedious process of healing, 
perhaps lose his hand, perhaps his life. 

The investigations in this regard belong to the branch of 
science known as ''Bacteriology/' and we will briefly outline the 
results of this science, leaving the details to be filled in by the 
teachings of the textbooks on this subject. 

MiCROOKGANic LiFE. Where are these germs, and how do 
they happen to get into the wound? Microorganisms are, w^e 
can truthfully say, omnipresent. They are present in the air, on 
the body, and within the body. They are constantly circulating, 
because they are very light, and the currents of air can carry and 
deposit them in a different location, and from there they can again 
be removed with the dust and other particles of matter, to be 
scattered broadcast. Therefore, we can say that they are every- 
where. However, they are not always under good conditions of 
life, and just as a person does not thrive well under all conditions 
of life, and on all kinds of food, so it is with these small germs — 
they do not thrive well on all kinds of food and under all condi- 
tions of life. It is only when they are under very favorable con- 
ditions of life that they will thrive, and this thriving is shown 
by a rapid multiplication of their numbers. Under unfavorable con- 
ditions these little germs will remain stationary. They will prob- 
ably not lose their life altogether, Imt they will be in a sort of a 
dormant state. This fact is very important. 

Conditions of Growth. What are the conditions favorable 
to their growth? The conditions var\^ for different kinds of 
microorganisms, and there are a great number of different forms 
of these organisms. They are not all of such a nature as would 
be harmful to the body, causing disease. Some of them are per- 
fectly harmless and may be carried in large numbers in the body and 
never cause any disturbance at all. 

The germs which really do cause disease are called "patho- 
GENic,'' while those which do not cause disease are known as non- 
pathogenic microorganisms. The pathogenic and non-pathogenic 
organisms require different conditions of life in order to thrive, 
but most of tliem are favorably situated when they have moisture 
and a certain degree of temperature and food. They do not 
thrive in a cold temperature. They do thrive, however, in a tem- 
perature about that of the normal body, sometimes a little less 

56 



and at times more. And they thrive if they have a certain amount 
of moisture (they need it if they are to increase in number). 
They also need a certain material for food. The three conditions 
of their life are: heat, moisture and food. Some of them require 
sunlight for their development, while some do not thrive on sun- 
light, it being very harmful to them. Some of them need oxygen, 
while others do not require it. Therefore, these different condi- 
tions of life are the elements which determine the existence or 
non-existence of microorganisms. 

The Body as Culture Ground. Inasmuch as these organ- 
isms are everywhere, and the human body contains moisture, is 
at the proper temperature, and furnishes food, it is a very good 
medium, or, as we call it, culture ground for these micro- 
organisms. 

Wounds in particular are exposed to a number of diseases 
which are traceable to their effects. In explaining the different 
microorganisms there will at the same time be explained the 
diseases caused by these organisms in wounds. They may also, at 
times, cause these diseases without wounds, or they may cause 
them in such wounds as are not easily found or readily percept- 
ible by means of an ordinary examination. In our clinical obser- 
vation we make a distinction in this : We sometimes speak of 
CRYPTOGENIC DISEASES as having an obscure cause. But the word 
cryptogenic is fast losing ground, because out of the dark and 
obscure we are learning to find the cause and entrance of micro- 
organisms. 

Points of Entrance. Wounds form an easy entrance to 
such microorganisms. They may enter in two ways: (1) From 
the outside; (2) or they may enter from the inside. Micro- 
organisms are always present in the body; they are in the normal 
mouth, in the alimentary canal, in the nose and respiratory tract 
and in the glands of the skin, etc. The glands of the skin are 
full of microorganisms, as we can demonstrate under the micro- 
scope and by culture; for instance, take a small piece of skin, 
wash it very carefully and place in a culture tube, and very often 
we will find, even after thus carefully treating it, some organisms 
are in the glands of the skin, which can not be rendered aseptic. 

58 



1. SEPTIC mFECT10N = 



THE STEEPTOCOCCUS' AND STAPHYLOCOCCUS 
INFECTIONS. 

The most common microorganism is that which causes the 
ordinary suppuration commonly called blood poisoning of 
wounds. If a wound be examined on the second day after it be 
produced, one would see, in a case where microorganisms had en- 
tered the wound, signs of inflammation, redness and swelling, and 
the patient would experience pain. The serum, when stained and 
viewed under the microscope, presents, besides the white blood 
corpuscles, as have been described under the discharge of wounds, 
some small bodies, at times arranged in a chain, and at other 
timics in clusters. These little bodies, which so readily take the 
stain, are the microorganisms. The most common organisms 
which produce infection of wounds are the streptococcus and sta- 
phylococcus, the former receiving its name because it grows in 
chains, the latter because it grows in clusters. It is a little round 
body or globule. These two kinds of organisms are the most 
common ; they cause the largest percentage of all the wound- and 
other diseases of the body. 

They enter not only through the wounds, but also through 
the pores and glands, wherever the body is exposed. When they 
enter they cause a great number of changes to take place in the 
body. Take, for example, the tonsil. This is an organ which 1ms 
large, irregular openings on its surface, and these organs are fre- 
quently injured in the swallowing of food. This injury ar scratch 
of the tonsil does not cause very much bleeding — the person hardly 
ever notices it— but if these little microorganisms are present, 
and find entrance in that little scratch, they find a well-tempered 
ground for their living; they will multiply very rapidly, and in 
a few hours that individual will have considerable inflammation 
of the tonsil. This inflammation will pass away, but the tonsil 
is connected with the lymphatic glands of the neck; therefore, 
these organisms, which have probably gathered in one of the small 
lymph-openings of the tonsil, find their way into tliose glands, 
and inside of a week or ten days that individual has a swelling of 
a ]{\rge gland of the neck, and in the center of that gland is an 
extensive gathering of microorganisms, which may cause an ab- 

GO 



scess, then another abscess, and so on; therefore, the infection 
from so slight a cause may lead to considerable destruction of 
tissue. (Lymph-adenitis suppuratia.) 

Charactekistics of Infections. Examinations show that 
when the staphylococcus is present in large numbers the signs or 
symptoms of the disease are different than when the streptococcus 
is present, and they differ again when both forms are present. In 
case the ' streptococcus only is present, the wound usually does 
not have much of a discharge, the swelling is not so prominent 
and the pain is not so great, but the individual becomes very sick, 
developing high fever, chills manifesting themselves. This form 
causes an infection which is very dangerous. We know that if 
this organism (the streptococcus) has entered, the disease is much 
more severe than if the staphylococcus has entered. If the staphy- 
lococcus has entered the wound, then the general infection of the 
body will not be so great, but the local infection will be severe; 
there will be some swelling, some discharge, pus formation, etc. 
The fever will not be so high. Very often, however, both these 
organisms are present in the wound at the same time, and then we 
have the so-called "mixed infection.'^ In this case we have fever 
and a severe sickness, and with this the formation of pus. 

Result of Infection. If these microorganisms enter, we 
have as a result a condition of the wound Avhich we call a septic 
infection. This is the common wound disease. This septic in- 
fection of the wound is not only a local trouble; that is, it shows 
its signs not only at the site of entrance of the organism, but it 
may spread, as we have seen in the case of the tonsil or teeth, 
throughout the body, causing its effects to be widespread. 

VIRULENCE OF ORGANISMS AND REACTION OF 
INDIVIDUAL. 

An interesting question is this : Are the above related con- 
ditions always present when these microorganisms enter into the 
wound, or do they only occur at times? This depends upon two 
conditions: In the first place, just as human individuals are pos- 
sessed of a different degree of vitality at various times, so it is 
with these organisms — they are of different vitality or strength 
under different conditions. As a rule, under the microscope they 
show the same appearance, but their strength is not always the 

62 



same. In speaking of the strength or condition of these organisms 
we use the term "virulence/' calling them virulent when they 
have great strength or vitality, meaning that in a particular case 
the organism is able to cause symptoms that are more severe than 
in another. 

The septic condition depends, therefore, upon the virulence; 
secondly, it depends upon the number of microorganisms present. 
If it were not for these two factors, wounds would become much 
more severely infected than they do. Microorganisms enter, but 
they do not always enter in sufficient number and in a high state 
of virulence; they are not strong enough to harm the human 
organism. 

A small number of organisms may be introduced into a 
wound and there will be no particular effect ; if a large number 
of virulent organisms be then introduced, there may also be no 
difference shown in the phenomena. Therefore, a third cause 
for the septic condition is found outside the microorganism and 
inside the individual. One individual may have the same num- 
ber of organisms -(virulent) gain entrance to the body as another, 
but it will be affected in an entirely different Avay. That is called 
the reaction of the individual. We know that if the human organ- 
ism is weakened by a long disease it is easily affected by a micro- 
organism, while if it were strong and healthy it would not be so 
easily affected. This is the individual reaction. On these three 
conditions— the virulence and numbers of tlie microorganisms 
and the vitality of the individual — depends the fact as to whether 
we have infection or non-infection. 

COURSE OF SEPTIC INFECTION. 

The possibilities after the infection of wounds are many. 
The most common course, however, is this : 

(1) After the local infection of the wound and the local 
effects of inflammation, with or without an exudate of pus, the 
inflammatory strength of the microorganisms may be exhausted 
and absorption or healing take place. 

(2) In many instances the microorganisms are carried fur- 
ther through the lymphatics, causing their inflammation on the 
way (lymphangitis), which often shows it superficially, as red 
streaks on the skin. The glands may suffer in the same manner, 

64 



the signs of this being enlargement, pain and tenderness 
(lymphadenitis). The specimen of such a gland shows con- 
gestion and often small abscesses. Sometimes, if the micro- 
organisms are of great virulence, the pus is too large in quantity 
to be restrained by the capsule of the gland, it breaks, causes 
pressure necrosis of surrounding fasciae. Even breaking through 
skin in the direction of the least resistance is comparatively often 
seen. 

(3) Blood circulation seldom, but at times, serves also as 
carrier of the microorganisms into the system, and it is then 
that the disease becomes the most dangerous form of blood poison- 
ing, SEPTICEMIA, SEPSIS (endocardial), or pyemia from pus form- 
ing in the blood. The heart easily becomes the seat of infection. 
Small granules and clots of blood of the ulcerous endocarditis be- 
come emboli anywhere, to start a new foeus wherever they are 
carried (metastatic abscesses). Thus abscesses in liver, kidney, 
bones, brain, skin, etc., may be formed in case of microorganisms 
being carried and deposited there by embolism. 

2. EEYSTPELAS. 

Another infectious disease of wounds is erysipelas. It is a 
disease usually characterized by an extreme redness and slight 
elevation of the epidermis, and is further characterized by a rapid 
spreading of this swelling and redness. It attacks the face more 
than other parts of the body. The infection may be carried into 
the inside of the organism — into joints, mucous membrane, serous 
cavities, etc. 

It is caused by a streptococcus, being produced by the intro- 
duction of these organisms into very small wounds (rhagades) 
of the skin. Probably in ninety cases out of one hundred the 
nose is the primary focus where these organisms enter and from 
which they spread very rapidly over the nose and entire face, and 
even over the whole body, from a very small point of entran(!e. 
The characteristic appearance of this wound infection is that the 
swelling begins abruptly from the normal skin. To be certain 
of the diagnosis, observe the border of the swelling and determine 
whether that border falls abruptly into the healthy skin. In 
severe cases the skin may be transformed into vesicles. The micro- 
scopic appearance is that of inflammation and filling of small 

66 



lymphatic capillaries with chains of cocci; formation of blisters^ 
local necrosis and local abscesses are very common. Lympli- 
giands and mucous membrane are easily affected, and exudates 
of any kind may form. Metastatic processes of the same nature 
as in sepsis may appear in any organ, but are most common in 
the brain in the form of an iniiammation of the membranes 
(meningitis). 

3. SUKGICAL DIPHTHERIA. 

Among the wound diseases, the diphtheritic infection, or 
diphtheria, was f ormery very important. 

Diphtheria is not a local disease of the throat only, but a 
general disease, an infection of another form from those we have 
hitherto considered. The microorganism, the action and effect 
of which produce diphtheria, is in the shape of a rod and is called 
a bacillus. These bacilli grow in the form of either chains or 
clusters, varying in size and virulence. 

Toxin and Antitoxin. Under favorable conditions these 
organisms grow very rapidly. They produce through their life, 
like all microorganisms, a certain kind of poison, which is called 
TOXIN. This toxin is a chemical substance and is very soluble. 
It can be separated or isolated, and if injected in solution pro- 
duces the same symptoms or signs in a body that the micro- 
organisms themselves produce in a body when they attack it. 
Gradually the body is filled until it is overflowing, as we say, 
with this poison. The symptoms caused by it are a general 
malaise, or disease, headache, high fever, delirium, etc. These 
symptoms are also caused by the toxin when injected. As the 
blood becomes gradually saturated with this toxin there develops 
in the body a substance which is antagonistic to the poison. This 
substance we call antitoxin. The toxin and antitoxin stand in 
the same relation to each other as, for instance, an acid and an 
alkali — they neutralize each other — and the result of these two 
coming in contact with, each other is a normal condition, if they 
are present in the same quantity and in the same strength. From 
this the importance of the discovery of antitoxin, as now used for 
the cure of various diseases, may be understood. We have been 
able to produce this antitoxin artificially in animals, first giving 
the animals the disease, bring the infection to a certain stage 
(strength or virulence), then extracting the blood from these ani- 

68 



mals^ taking out of the blood this substance after they have over- 
come the disease, and introducing it in a liquid form into the 
body of a person filled with the diphtheritic or other toxin, thus 
giving to the body an opportunity to fight the toxin before it has 
had time to develop the antitoxin in its own hlood. 

As it is with the toxin and antitoxin diphtheria, so it is with 
most of the diseases of this nature, and nowadays we have anti- 
toxins for the streptococcus and staphylococcus — not so well 
defined, however, as the antitoxin of diphtheria. We have an 
antitoxin for pneumonia, for scarlet fever and for tetanus or 
lockjaw. 

In other words, we try to introduce into the body these chem- 
ical substances which are formed in the body itself when the body 
overcomes the disease — when the microorganism succumbs to the 
strength of the body and the blood. The first idea of the possi- 
bility of fighting a disease in this way was given to us through 
the use of vaccination against smallpox. 

It was well known that when a person had once gone through 
the disease of smallpox that person was hardly ever attacked 
again. And so very ingenious physicians, long before the days 
of bacteriology or bacteriological knowledge, made use of the con- 
tents of the pustule in a mild form to introduce it at a time when 
the body was not affected with the disease in order to prevent 
such an eruption as smallpox. The physician has not only ac- 
complished this, but he has been able, in light cases, to prevent 
the development of severe symptoms, and this has gradually proved 
to be such a success that it has been used forcibly upon the peo- 
ple who Avould not submit to it. It has been proved by statistics 
that in the countries where vaccination has been compulsory small- 
pox has been almost entirely wiped out from the list of diseases. 
In diphtheria we have the same experience, the question of the 
administration of antitoxins having been dealt with in many 
cases in a drastic manner. XoAvadays diphtheria is not regarded! 
as a very serious disease, for it can be cured with almost a cer- 
tainty if it be recognized very early. 

If a wound is infected with diphtheria it shows an inflam- 
mation ; the blood supply becomes increased ; the mucous mem- 
brane swells up and becomes red from congestion^ and, inasmuch 
as the nerve endings are impinged upon by the swollen tissues, 

70 



there is pain. So that when the muscles, for instance, of the 
phar3'nx or the tongue (the tongue is more resistant than the 
pharynx or tonsils) contract, they compress the nerve fibers, and 
that is the pain that people have in opening the mouth, swallow- 
ing, etc. 

DiPHTHEEiTic Membrai^e. Immediately after inflammation 
sets in these microorganisms affect the part in such a manner that 
a fibrinous exudate forms, and discharge is deposited upon the 
surface. Quite a number of these bacilli are contained within it. 
We call this fibrinous mass, which is closely adherent to the sur- 
face, A MEMBRAXE. Such a membrane may be easily brushed off, 
or it may be closely connected with the underlying tissue. Some 
of the fibers may extend down into the cells composing the tissue, 
and it will then be very hard to remove it. If the destruction of 
the cells has been extensive, the membrane may have quite a deep 
foundation, in which case, when we try to remove it, we get very 
near the superficial vessels, and immediately upon removing it 
the surface will bleed. 

DisTiNCTiox Between Croup axd Diphtheria. The above 
is the means of drawing a distinction between the two important 
diseases, croup and diphtheria. In the one we can remove the 
membrane ver}^ easiN, when the surface beneath will l^e found 
to be more or less normal. In the other we Avill find that the 
membrane may be removed, but the surface will be found bleed- 
ing and portions of the membrane will he left adherent. In the 
former the disease is called "croup" (croupous exudate), while 
in the latter it is known as diphtheria. The first mentioned con- 
dition is very common, there being simply a fibrinous exudation 
in the mouth, which contains microorganisms, but not the diph- 
theritic bacillus. In the other case, however, where the epithelium is 
destroyed, the fibrinous discharge contains the true "Klebs- 
Loeffler" bacillus', and if we take such a piece of membrane and 
place it in a culture medium we can rapidly grow a pure or mixed 
culture of diphtheria. 

Mixed Ixfectio^^. If the Ivlebs-Loeffler bacillus appear 
alone, or. as we say, in a "pure culture," then they will cause 
no other than the above-mentioned symptoms. But they very 
often appear together with the streptococcus and the staphylococ- 
cus, and in destroying the tissue they open a field for the entrance 

72 



of these micro organisms, the result of the action of which has 
already been described. 

When these organisms get into the blood they cause a disease 
called sepsis, the most severe type of this kind of infection being 
that caused by the mixture of the streptococcus and the Klebs- 
Loeffler bacillus, producing what is called septic diphtheritis, a 
very violent, rapidly fatal disease. It is so violent, and the de- 
struction goes on so rapidly, that the blood often has no oppor- 
tunity to coagulate, therefore almost continuous oozing takes place. 
The blood may be mixed with the fibrinous material thrown out, 
causing the so-called blood or black: diphtheria. 

Types of Diphtheria as Wound Disease. We distinguish 
three types of such diphtheritic infection. The first one has been 
described, in which the surface remains more or less intact; that 
is, the croupous diphtheria. The second form is where some of 
the membrane has been destroyed, this constituting the ulcerous 
diphtheria. The third one is the very rapidly growing form, 
in which, by necrosis, a sort of pulp is formed out of the tissues, 
this taking place so rapidly that the pulp overlies the tissues and 
mixes with the blood. This form is known as the pulpous 
diphtheria. 

These three types of disease also appear upon the skin at 
times, but they have l^ecome a very rare occurrence nowadays 
because we are very careful in cleansing our wounds. During 
wars, wound diphtheria sometimes appears because the wounds 
can not be well taken care of, and among the soldiers in the field 
the disease still appears. In the mouth the pulpous form does not 
appear so often, the ulcerous type being the most common. 

4. TETANUS. 

Among the diseases and accidents of wound healing is one 
which is not very common, but is most important because it is 
very dangerous, and because there are few cases of that disease 
which escape the fatal result. This is tetanus, or "lockjaw." 
Before the bacteriologist found the cause of this disease it v/as 
thought that tetanus was due to some other cause than micro- 
organisms. 

What is tetanus, or lockjaw? It is an acute wound dis- 
ease, with a number of symptoms, of which tonic contractions 

74 



of the muscles are the most prominent. Tetanus is a tonic con- 
traction of certain groups of muscles, chiefly of those of mastica- 
tion, as the masseter and pterygoid muscles (trismus). All the 
muscles attached to the lower jaw are affected by strong contrac- 
tion. Therefore, the disease was named lockjaw. 

The disease is not confined to this one set of muscles, how- 
ever. All the muscles of the body play their part, the degree 
being according to the type and strength of the disease. One of 
these groups of muscles most affected is those of the back, tonic 
contraction of which causes the head and lower part of the body 
to be drawn l:)ackward, forming an arch or bow of the same. 
This action of the muscles is known by the technical term 
''opisthotonus." In extreme cases this is carried to such an 
extent that the l)ody rests on only two points, the heels and the 
head. Another group of muscles very often affected are those of 
respiration. Their tonic contraction is often fatal through suf- 
focation of the patient. 

In the course of the disease the contractions come on in re- 
peated attacks, an attack usually lasting for a period of ten or 
fifteen minutes, but sometimes persisting for one or two hours, 
and in some very severe cases the attacks are so frequently re- 
peated that the patient has only a few moments' rest between the 
contractions. 

Besides the contraction of muscles there may be unusually 
high fever (hyperpyretic temperature). 

The result of this disease is, as stated, nearly always fatal. 

Etiology. The cause of this disease is an infection of a 
wound. Often the point of eutrance of the infection is not found. 
It may be a very small punctured wound, which is not noticed at 
all by the patient. The real cause of the disease is a bacillus of 
a club shape. 

This bacillus has been found in almost every case of tetanus 
where thorough investigation has been made. It was found that 
this microorganism is commonly found in the soil, and that it 
can persist in the dirt for a long time without thriving, but if 
brought iuto a wound it begins to multiply rapidly and to form 
a certain poison, and it is this poison or toxin which ])roduces 
the contraction of the muscles. We know from experiments that 
clieuiical ngeuts uiay produce tetanic coutractions of the muscles; 

76 



for instance, "cnrare/^ a violent poison which was used by the 
Indians for poisoning their arrows, can prodnce tetanic contrac- 
tion of the muscles. 

We explain the action of toxin produced b}' the bacillus tetani 
in the same manner as we explain the action of curare. The 
microorganisms enter the wounds with the soil. Under ordinary 
circumstances these microorganisms are introduced with dirt 
which is on instruments, knives, glass and various bodies which 
produce the wounds. Gunshot and explosion Avounds are very 
often the cause of infection by the bacilli of tetanus, because 
powder and various forms of cartridges enter with soil particles 
containing these microorganisms. It is well known that in wounds 
produced in Fourth of July celebrations this tetanic infection is 
very often produced. 

Tetanus AisTTiTOXiisr. We have an antitetanic serum, used 
for the prevention and cure of such tetanic infection, this anti- 
toxin being obtained in the same manner as the antitoxin serum 
used in diphtheria. 

5. HYDEOPHOBIA. 

There are a number of other acute diseases which may affect 
wounds; amongst these is hydrophobia, a comparatively rare 
wound disease, which shows hardly any change in the wound. 
These wounds are, as a rule, produced by a dog bite, but the bite 
of other animals may also produce it. As stated, in these wounds 
there are no apparent changes; the wound does not differ from 
any other wound ; at the same time, from analogy we may infer 
that this is also a microbic disease. So far, however, no one has 
been able to find the particular microorganism causing this disease. 
It is, however, possible to extract a certain material, and, inject- 
ing it in an attenuated form, prevent or cure liydrophobia in th? 
same manner as the antitoxin is used for other diseases. 

6. OTHEE ACUTE INFECTIOUS DISEASES. 

The infections mentioned so far are the main diseases whicli 
may affect wound liealing. Together they form a group whicli 
we call the acute infectious diseases of surgical interest. 
There are a number of acute infectious diseases which, not af- 
fecting wounds, as a rule, have no particular interest for the 

78 



^urgeou. However, pathologists now know that the invasion of 
the body by microorganisms most likely occurs through the small 
wounds inside the body. For instance, typhoid fever is an acute 
infectious disease; scarlet fever is an acute infectious disease: 
measles, recurrent fever, spotted or typhus fevers, malaria, etc., 
all these are acute infectious diseases. But the microorganism 
producing these pathologic conditions enters the body not 
through the external wounds but, most likely, through wounds 
internally, or through the spaces which are left by natural secre- 
tions. It is only within the last few years that we have known 
the real cause of malaria ; we now know that this is a wound disease. 
The mosquito produces a very small wound in the body, and by 
this means transports into the body a certain microorganism 
which produces fever in certain intervals, two, three or four days. 
This disease we call malaria. 

It is, therefore, a wound disease; but the wound thus pro- 
duced by the mosquito is so small that heretofore malaria has 
not been called a wound disease. But since these diseases have 
been gradually found to be wound diseases, and it is not unlikely 
that typhoid, recurrent and typhus fevers are also such wound 
diseases, although not as yet classified as such, certain complica- 
tions of these diseases have a great deal of interest for the sur- 
geon, as they may cause abscesses or exudates of other kinas 
requiring operations. 

CHRONIC WOUND DISEASES. 

There is another group of wound diseases which is of interest 
to the surgeon, namely, the chronic wound diseases, of whicJi 
there are four main types : Tuberculosis, syphilis, actinoimy- 
cosis and leprosy. These four types have characteristics which 
differ from those of all other chronic diseases. 

What is the meaning of the words "acute" and "'chronic"? 

An ACUTE disease is one which has a rapid, quick course, at- 
tacking the body suddenly, or with a sudden onset, lasting a lim- 
ited time, and then ends with a cure, a fatal result or the trans- 
formation into a chronic disease. A chronic disease is one which 
sets in gradually, progresses slowly, until it develops into a certain 
type, then, with certain ups and downs, lasts for a long time, 
finally ending in a cure or a fatal result. This division into 

80 



i 



acutc3 and clironic diseases is not a very scientific one^ because an 
acute disease may become clironic, and a clironic disease may 
show acute exacerbations. The distinction, however, is practical. 

1. TUBEKCUL081S. 

Etiology. The cause oi tuberculosis is the growth of a 
certain microbe within the body — a bacillus or rod-shaped organ- 
ism, with rounded ends, which can be cultivated on certain media 
in characeristic shape. 

Symptoms. The bacillus of tuberculosis enters most cases 
through wounds. These organisms may be in contact with the 
normal body for hours and days, and will never affect the same 
at all, but if we produce a small wound on the surface and rub 
them into this wound we will soon produce a certain change 
around that area which is characteristic of the disease. The result 
of the invasion of the microorganisms of tuberculosis is an in- 
flammation, but it is an inflammation different from that produced 
by organisms heretofore mentioned. It is from the beginning a 
chronic inflammation. There will be redness and swelling to a 
very slight degree. Soon, however, an infiltration of leucocytes, 
which will have a tendency to form into connective tissue, will 
take place, and that is the characteristic of the chronic condition, 
viz., a tendency to form connective tissue. This, under ordinary 
circumstances, would mean a healing of the disease, because the 
connective tissue would form a scar; but most of these diseases 
do not stop there. The connective tissue is of such a nature that 
it breaks down easily and rapidly. It forms, breaks down, forms 
again, breaks down again ; so there is constant formation and 
destruction of tissue. We might say it is a constant attempt of 
nature to cure, with a constant failure of nature to heal. This is 
characteristic of tuberculosis. Whenever we have an apparent at- 
tempt of nature to heal, and then a breaking down, we can, even 
from this symptom, often make a diagnosis of tuberculosis. We 
know, for example, that glands of the neck are very commonly 
the seat of tuberculosis, but they are also often the seat of infec- 
tion from the teeth. The natural result of extensive caries of 
the teeth is infection of the glands of the neck, but infection 
produced by this means acts differently from the infection pro- 
duced by the tubercular bacilli. In staphylococcus infection of 

82 



the giands^ the pus breaks tlirough the skiu^ aud tlien permanent 
healing takes place. But ii it is tuberculosis, and the gland swells 
up, forms an abscess, a little watery pus runs out, it heals, swells 
up again, is tender for some time, breaks again and runs out, then 
closes; and so it repeats itself for months and months, perhaps 
years, until nature succeeds in eliminating the microorganisms, 
making them weaker and weaker and finally replacing the very 
slightly resistant tissue by healthy tissue — then it will heal. From 
the original point of entrance the tubercular process is carried 
throughout the body in different manner, but most commonly by 
means of the lymphatics. 

TUBEECULAR INFECTION OF LYMPHATIC GLANDS. 

Structure of the Lymphatic Glands. These glands have a 
more or less elliptical form. They are oblong in shape and con- 
sist of a reticulum — a marrow substance — the whole surrounded 
by a capsule. The capsule consists of connective tissue, while 
between the. fibers composing the network, or reticulum, are to be 
found white blood corpuscles. 

Every gland has a vessel of an arterial character, another of 
a venous character, or several of them. The blood which enters 
the gland enters by way of the artery, passes through the network 
of the gland, has no well-defined wall in this structure, and then 
leaves the gland by way of the veins. Besides these vessels there 
are the lymphatic vessels, through which white blood corpuscles 
enter the gland, some remaining and others passing out through 
the efferent lymphatic vessel to another gland, or to a larger 
lymphatic. This current of lymph is a perpetual current, and 
on its way some of the white blood corpuscles remaining in the 
gland fall apart, some remain where they are formed, and others 
pass from one gland to another. The gland is a blood-forming 
organ. 

A wound of the skin, or tonsil, or mucous membrane, may be 
complicated by the entrance of microorganisms of tuberculosis in 
sufficient number. It is to be noted that they enter very seldom 
through the blood vessel directly, but into the tissues, and from 
the tissues they are carried on to the lymphatic vessels. Once 
in a while it happens that the bacilli enter through the blood 
vessel; if they do, then they pass through the system very rapidly 

84 



and do not remain stationary. But if they pass, as is the rule,, 
through the lymphatic stream, on account of the slowness of this 
stream it may happen that they remain in the gland. 

SYMPTOMS. 

1. Inflammation and Infiltration. The immediate 
result of the entrance of some of these tubercular bacilli will be 
that they multiply to a certain degree, and that they will pro- 
duce inflammation, which is characterized by the formation of 
leucocytic infiltration. These leucocytes will appear in no way 
different from those already in the gland. We will only observe 
that the gland is filled with leucocytes to a greater extent than in 
the normal condition of the structure. Under sach conditions it 
is difficult to recognize the fine network of the normal gland. 
This is the first symptom. 

2. Swelling. As a result of this inflammation and in- 
filtration the gland swells up and serum is spread throughout the 
gland, stretching the tissues. 

3. Formation of Giant Cells. The next result, after 
days of existence of these tubercular bacilli, will be the forma- 
tion of a peculiar kind of cell which is present in most cases of 
tuberculosis — a cell which is more or less epithelial in character. 
This cell contains a number of nuclei near its border — they are 
wall-standing nuclei, the center of the cell being more or less 
granular. Such cells, because they are quite large as compared 
with the others, are called "giant cells,^' and we say, as stated, 
they are characteristic of the tubercular processes. But, as stated, 
it is a peculiar giant cell. It is a giant cell which has its nuclei 
near the border, the center more or less falling apart and disin- 
tegrating. In case of other giant cells the nuclei are central; for 
instance, in the growth of sarcoma. 

4. Embryonal Cells. Around this giant cell there form 
out of the infiltration cells peculiar cells, which we see only in 
the embryo: connective cells with large nuclei. This gives a 
gland of different appearance. We see a giant cell surrounded by 
tissue of an embryonal character. 

5. The Tubercle. This condition will last only for a cer- 
tain time; then the giant cell will begin to fall apart, the em- 
bryonic cells will begin to separate, and in their place there is 
sometimes only half a cell remaining, the other half being oceu- 

86 



i 

I 



pied by tissue which does not take any stain, but consists of small 
granules. On account of its not taking a stain it has more or 
less of the color of protoplasm without stain; that is, it is yel- 
low. It sometimes becomes even liquid or semi-liquid, and when 
such a gland is cut the naked eye can distinguish these small 
yellow spots with the surrounding congested area. This degene- 
rated area is called a tubercle. Several such tubercles may form 
in a gland, and often a great number of them. If within a 
short distance there is another such tubercle, and still another, 
they disintegrate very rapidly by a coagulation necrosis and flow 
together, gradually, as a result of this process, there is formed 
a mass of more or less disintegrating tissue of a yellowish charac- 
ter and of the consistency of cheese. This is called a cheesy 
DEGENERATION of the gland. The process is characteristic only of 
tuberculosis. 

Characteristics of Tuberculosis. The giant cell forma- 
tion, the presence of embryonic cells, the cheesy degeneration 
are characteristic of tuberculosis. The cheesy degeneration 
spreads very rapidly, involving a large area; several such areas in 
the gland flow together, and sometimes the whole gland is trans- 
formed into a cheesy mass, nothing of the tubercular structure 
remaining, except here and there a point of tissue on the outer 
border. In the meantime the connective tissue surrounding the 
gland has become inflamed and adherent one to the other, form- 
ing a paquet, as we call it, a regular string of glands, very often 
seen on the neck, in which case the string of glands may extend 
from the ear clear clown to the sterno-cleido-mastoid muscle, or 
perhaps to the space in the arm, or even alongside and down two 
or three inches below the axilla. Sometimes they enlarge consid- 
erably and form tumors on the neck, the neck being especially very 
commonly the seat of tuberculosis of the glands. 

Mixed Infection. If an accidental infection with another 
bacillus, bacterium or coccus takes place, then the process begins 
to look a little different. If, for instance, it happens that a 
staphylococcus enters through the lyuipliatic vessel, finding its 
wav also into the gland, it will form an abscess, which will break. 
Tberefore, such a gland may break through the skin and form 
a running sore, which will persist for a long time. A fistula 

88 



forms, constantly draining a thin, fine liquid containing tnbercu 
lar bacilli and staphylococci and debris of the neck. 

Etiology. How does it happen that the glands of the neck 
are so commonly affected with tuberculosis? It takes place in 
the same manner as other infections. The bacillus of tubercu- 
losis finds its way into the glands of the neck through the openings 
of the mouth. We know that the tonsil is buried in between the 
anterior and posterior glosso-pharyngeal arch ; it is a projecting 
organ with lymphatic spaces on its surface. These projecting 
tonsils are easily injured. The food passes by them, and some- 
times particles are not well masticated, or, containing foreign 
bodies, may scratch or lacerate such a gland very easily, and the 
infectious material finds its way in through the tymphatic spaces. 
That is the reason the tonsils are so commonly the point of en- 
trance of the tubercular process, especially in children. The 
tubercular bacillus reaches the floor by expectoration, mixed with 
the dust and inhaled, adhering to the lining of the mouth, and 
if the food in passing by injures the tonsil or palate the bacillus 
may enter and set up the tubercular process, while it is innocuous 
if it remains on the mucous surface. Children often crawl upon 
the floor where expectoration laden with tubercular pus has been 
spread, thereby infecting their fingers and through the same into 
the mouth. 

The lymphatic stream from these glands goes directly dov\^n 
to the glands under the jaw, the so-called regionary glands of the 
neck, and this chain of glands is the first to be infected. The 
tubercular process does not involve the glands of the back, as 
does the syphilitic process. If the tubercular process, on account 
of its history of pathologic origin, affects the glands under the 
jaw and is not arrested it passes down the lymphatic stream into 
other chains of glands, which again temporarily stop it. Nature 
seems to have provided in the chains of glands a sort of protection, 
because if these glands were not present the infection would go 
directly down into the larger branches of the venous system and 
very few people after such an infection had taken place would re- 
main alive. Therefore, it is fortunate that we have a large number of 
glands on the neck to act as a protection against all kinds of 
infections which may gain entrance to the body in the manner 
described. 



90 



Spontaneous Healing. We know that there is a sponta- 
neous healing of tuberculosis, that this consumption of the gland, 
as we may also call it, can heal out spontaneously. By removing 
the glands entirely we can eliminate the process, certainly arrest- 
ing the process of infection ; but spontaneously they heal also. 
If such a gland has enlarged to a certain size and has not burst 
its capsule — on the contrary, if the capsule has become very hard 
and resistant — then gradually all the tissue in the gland will 
be destroyed and nothing will remain but the cheesy mass pro- 
duced by the destructive action of the tubercular bacilli, and here 
and there, as stated, a small island of tissue. In this event the 
result will be, especially if the staphylococcus has not entered 
to melt the tissue down very rapidly, that the tubercular bacilli 
will lose much of its nutrient material ; therefore, it will be- 
come very weak ; it will exhaust itself, as we say, and die out. 

As the bacilli die out there will remain only a few cells 
within the gland of a character described — the epithelial em- 
bryonal cells — and these form the beginning of the cure of tu- 
bercular process. 

In proportion as the tubercular bacilli die out, these cells 
become stronger, forming a strong connective tissue, which will 
envelop the rest of the tissues with a sort of a capsule (encapsula- 
tion), thus surrounding them with scar tissue, enclosing them and 
rendering them harmless. Sometimes within this capsule there 
persists a small number of tubercular bacilli, which remain in 
a sort of dormant state for a long time; they are harmless be- 
cause there is not enough nutrition to enable them to multiply' 
again, but if nutrition is added they begin the destructive process 
again. 

And so it is with tuberculosis everywhere — not alone in 
the gland. 

We notice that some children at the age of four to six 
years develop large glands in the neck, and we are sometimes 
even inclined to remove these glands, but instead we nourish and 
nurse the child a little better, and then these glands become liard 
and diminish in size. What is the cause of this diminution? 
It is nothing other than that the tubercular bacilli have become 
weaker and the tissues surrounding them have become stronger. 
They are encapsulated, and, therefore, they remain innocuous, 
... 92 



and the child goes on and develops and grows strong until he 
becomes, we will say, sixteen or seventeen years of age, when from 
some cause, as a recurrent or wasting disease, the child becomes 
weaker again, the tubercular bacilli take on new strength and in- 
crease in numbers, and there is a reinfection and a new breaking 
out of the tubercular process. And so it is with the tubercular 
infection of bone. In fact, this occurs more often in the case of 
bone than in the glands. The infected area apparently heals out, 
but the bacilli simply remain dormant, perhaps for years, and all 
of a sudden the individual falls, breaks the bone in the neighbor- 
hood of the old infection, or a concussion of the bones, hemorrhage 
takes place within the bone, and there is a new breaking out of 
the dormant tubercular bacilli. So it is, also, with the lung 
tissue — the most common seat of bacilli of tuberculosis. Th.e 
tuberculosis in the lung starts in the least ventilated portion. We 
know that the bronchi divide inside of the lung, and one of them 
passes to the apex of the hmg, anrl it is this portion of the lung 
that is least ventilated. Unless a person breathes deeply, the 
alveoli at the apex are not ventilated well; here the tubercular 
bacillus, which is anerobic, is under the best conditions of growth; 
consequently tuberculosis at this point develops very rapidly in 
the manner alreadv described. But here, also, the disease may 
heal spontaneously through the development of a capsule around 
the tubercular process, when the bacilli will remain dormant, 
sometimes for many years, until through some accident the cap- 
sule breaks and the process starts afresh with the rapid spread of 
the infection and the speedy rlisintes-ration of lung tissue. That 
is called ^^quick consumption." This is, perhaps, the most in- 
teresting phase of the pathology of tuberculosis. 

SUEGICAL TUBEECULOSTS OF OTHER ORGANS. 

The tubercle bacillus may develop in any part and tissue of 
the body. If it reaches the organ by the way of the circulation 
it is usually in the shape of an embolus. A formation of tubercles 
is the result, and the process is similar to that of tuberculosis 
of the glands. The final outcome may also be (1) spontaneous 
healing or encapsulation; (2) a cheesy degeneration, with pressure 
atrophy and melting of the surrounding tissues; (3) mixed in- 
fection, with abscess formation. 

94 



TUBERCULAR ULCERATION. 

Upon the surface of skin and mucous membrane tuberculosis 
acts somewhat ditferent. There is also a formation of tubercles, 
but from their perishable nature they soon become softened and 
break down, resulting in ulcers. These ulcers are characteristic; 
they have irregular borders, with yellowish, distinct spots, which 
prove to be tubercles. They have slight tendency to heal. Their 
discharge is thin, watery and contains tubercle bacilli. 

Tuberculosis of the skin is called lupus. 

2. SYPHILIS. 

Syphilis. The second most important chronic inflammation 
is caused by the syphilitic infection. 

Symptoms. The syphilitic virus, whether it is a microbe oi- 
some other kind of infectious material, enters the body through 
an external wound, producing at first an inflammation of a pecu- 
liar character, which we call initial sclerosis. 

1. ScLEEOSis. An infection with syphilitic virus, as in 
other infections, is always produced through wounds. The wounds 
through which the virus enters is not necessarily very large — a 
small break in the skin is sufficient to allow the entrance of 
syphilis. Some scientists have found microorganisms of the shape 
of a bacillus in such wounds, but they may be accidental. We 
can not say that there is any connection between the micro- 
organisms thus far found and the afl:ection which we see in the 
syphilitic infection. 

This small wound, when infected, at first becomes swollen. 
This swelling is in the epithelial portion of the skin itself and 
in the subcutaneous tissue. The epithelium over that swelling, 
which we call the primary sclerosis, is soft, succulent, and the 
cells which compose the swelling are large cells, some of which 
have large nuclei. Underneath the swelling we find, at first, the 
infiltration which is so characteristic of every inflammation — the 
infiltration with leucocytes. 

2. Ulceration. From this point on the result of the in- 
fection is different from that produced by any other infection. 
Some of these hardened portions of the sclerosis break down in 
such a manner that they soften by regressive changes and form 
an ulceration. This ulceration is the result of some processes in 

96 



the blood vessels, which are characteristic of syjDhilitic infection 
only. These changes in the blood vessels are known as endar- 
teritis,, an infiamniation of the inner wall of the artery. An 
artery is composed of three walls: An inner lining consisting of 
a very thin membrane, a middle wall consisting of muscle fibers, 
this being the contracting element which allows of a dilatation 
and contraction of the artery, and an outer coat of connective 
tissue. The inflammation of this very fine internal membrane 
lining of the artery is characteristic of the syphilitic process. The 
result is a thickening of the inner wall. Because of this thicken- 
ing the lumen becomes smaller, and as a direct result of this 
diminution in caliber the blood can not pass through the vessel; 
consequeutly there is an obstable to nutrition, and often in these 
cases the vessel finally becomes almost closed up. The result of 
such an endarteritis is apparent: As the blood can not reach the 
capillaries because of the closing up of the artery, the circulation 
stops; consequently it is found that the part supplied by the 
vessels affected is poorly nourished, and, inasmuch as it does not 
receive the normal amount of nourishment from the artery, it 
must get it from other sources, which do not suffice, and so it 
happens that these parts die, and their death, constituting what 
is called local necrosis, is the cause of ulceration. We have, then, 
an ulcer, an eaten-out portion of the skin, where the central por- 
tion has died and been discharged outward .as decayed tissue, and 
only half-destroyed tissue, which gets its nutrition from the neigh- 
borhood, remains as the border of such an ulcer. 

That is the syphilitic ulcer. It is characterized and well 
distinguished from that of tuberculosis with irregular borders, 
partly adherent necrobiotic tissue, some tendency to spontaneous 
healing, fresh decay of newly-healed tissue, lard-like necrosis. 
This occurs not only in the skin, but may take place in any 
portion of the body where the syphilitic poison is present. 

3. G-ENERAL Infection. The process does not stop with 
primar}^ sclerosis and local ulceration. The infection hardly 
ever, perhaps never, remains local, but it passes from the initial 
point throughout the system and infects the whole body by way 
of the lymphatics and blood vessels. The virus passes through 
the skin first into the veins, and as it passes into the veins it gets 
into the general circulation and through the h-eart and all over 

98 



LofC. 



the body. On the skin it forms copper spots (roseola). Tiie 
blood circulation, however, does not show the effects so clearly as 
the circulation of the lymphatics. There are lymphatic vessels 
in the neighborhood of this ulceration, and through these lymphat- 
ics the virus is carried on to the first station of the lymphatic 
circulation — the gland — and here it causes a lymphatic syphilis — 
syphilis of the lymph gland (bubo, lymphadenitis). It multi- 
plies, attacking many glands; these become hard, enlarged and 
irregular. 

Passing on further, it reaches the general circulation, after 
which it begins to inflame gradually the different organs of the 
body; it causes an inflammation of the spleen, the bones, the 
brain, the liver, etc. There is hardly a tissue into which thi^ 
syphilitic infection may not find its way, and in most of the 
cases it is due primarily to the infection of the smallest blood 
vessels, called endarteritis. If, therefore, syphilis be character- 
ized as an inflammation, we can say it is a wound disease of 
such a nature that it causes chronic inflammation, which is char- 
acterized by the formation of connective tissue (sclerosis), plus 
an endarteritis. 

Eesults of General Infection. The disease is usually re- 
garded clinically as having an acute, a secondary and tertiary 
stage. These distinctions are practical and of general im- 
portance. 

Most syphilitic infections gradually become secondary and 
tertiary, if not treated. The primary symptom was regarded as 
the sclerosis, or acute syphilis; the secondary stage as the general 
eruption, and the tertiary stage as the destructive condition. It is 
true that the primary and secondary forms are of such a nature 
that they may disappear and leave no sequelae. 

The so-called tertiary stage, however, always leaves sequelae. 
When the process has reached that stage, it destroys the tissues, 
which are not replaced. For instance, if the nasopalatine bone>5, 
which are so often the seat of this tertiary stage, be destroyed, 
or are eliminated, or if the nasal bone be destroyed or eliminated, 
these are not replaced, and there is left a scar, or a cavity, which 
forms a serious defect. These are the results of the tertiary stage 

100 



of syphilis. The tertiary stage of syphilis shows a characteristic 
formation called gumma. Macroscopically, it appears as a mass 
of yellowish, poorly vasculated, and therefore usually yellowish, 
tissue, with the consistency and elasticity of rubber. Microscop- 
ically, it is a mass of granular, necrobiotic tissue, with portions of 
poorly formed fibers and cells, surrounded by the sclerotic tissue 
of chronic inflammation, and if arterioles are to be seen, they show 
the characteristic endarteritis. 

3. ACTINOMYCOSIS. 

Etiology. The cavities formed by the caries of the teeth 
are in most cases the primary focus of entrance for this virus, 
but not in all of the cases; in some it gains entrance through 
the alimentary canal, and again it enters the lungs. 

The virus of actinomycosis is a well formed protoplasmic 
individual, which derives its name from the processes extending 
out from more or less elliptic or spindle-shaped bodies. These 
organisms appear in colonies, growing in such a manner that one 
individual joins the other, forming a sort of crown, with the 
processes referred to extending directly outward. When a small 
colony of these parasites is placed under the microscope, one sees 
a darker area, band-like, with small processes extending directly 
outward. At times they grow in a circle or ring-form. 

(1) This pathogenic microorganism enters the body usually, 
as stated, through a carious tooth; probably ninety per cent of 
the cases which have been known were of such an origin. The 
tooth is loosened in its socket, and the infection thus gains en- 
trance, passing (thus h'ke the other organisms) down into the 
space between the jaw-bone and the periosteum of that bone, caus- 
ing an inflammation of a chronic nature, an ostitis, and a peri- 
ostitis. That is the beginning of the inflammatory process caused 
by the actinomycosis — a lump on the jaw, resembling a periostitis 
from an ordinary infection of streptococcus and staphylococcus. 

At this stage the effect of the actinomycosis is not to be sep- 
arated from that produced by the ordinary periostitis caused by 
the staphylococcus. There is, however, immediately afterward a 
stage where it can be easily distinguished, when the part affected 
has become liquefied. The inflammatory process generally reaches 

102 



a stage where an abscess has formed^ and from that moment the 
disease is easily distinguished. This is very important, because, 
if it is not realized at that moment, the process can reach quite 
an extent and become dangerous to life. It can be diagnosed at 
this time by the nature of the pus. If this abscess breaks or is 
opened, and the pus is placed on a slide, by looking at it by good 
light one may see that the pus has some small pearls, which seem 
to be thicker than the rest of the pus. These little pearls — sago 
like — are nothing but the colonies of the microorganisms which 
are present in large numbers in the pus. If one of these small 
seed be stained and examined under the microscope, one may see 
distinctly the shape of the microorganism. 

The inflammation produced by this organism is exceedingly 
chronic, not like a streptococcus or staphylococcus, which forms 
an abscess that opens and discharges, and then heals, if there is 
no necrosis of bone. In actinom3^cosis the necrosis of bone is the 
common occurrence, this necrosed bone having very little tendency 
to separate from the healthy bone, there are granulations form- 
ing which contain groups of these parasites. These cause the dis- 
ease to spread alongside the lymphatics. Very soon the lymphatics 
beneath the jaw become the seat of a process of suppuration, witli 
the formation of granulations of a chronic character, for weeks 
and weeks. The glands adhere closely one to the other, forming 
large clusters along the neck and are very hard; the skin over 
these clusters becomes considerably infiltrated, hardened, so that 
it becomes difficult for the patient to move his head. G-radually 
this inflammation passes downward through the lymphatics to 
the sternum and beneath it, which is characteristic of the disease. 
It causes rapid inflammatory changes in this region, the char- 
acteristic pus being formed in the mediastinal space, forming 
abscesses which are absolutely incurable, and which are usually 
the cause of the death of the individual. 

(2) The form of the disease which is due to the entrance 
of the microorganism through the alimentary canal, however, is 
much more dangerous. When this bacillus is swallowed and passes 
through the stomach, it is easily received into the glands of the 
intestines, and from there into the glands adjoining the intestines, 
the mesenteric glands. Therefore, from the intestinal canal the 
actinomycosis may enter the body and form large masses in the 

104 



abdomen of glandular infections and suppurations which are very 
difficult to diagnose^ because there is no possibility of seeing the 
pus, and the condition can only be diagnosed when the micro- 
organisms have broken back into the intestines, and are discharg- 
ing with the fecal matter, a microscopic examination revealing 
microorganisms of this character in the stool. 

(3) There is a third possibility of actinomycosis infection 
of the body, and that is by the microorganism entering the lung. As 
a result of that chronic inflammation, there is a pneumonia, but 
of a peculiar type; it is not a croupous (acute) pneumonia, but a 
chronic, slow pneumonia, with constant hemorrhages, something 
like a tubercular process or consumption. The patient will have 
pains in the chest and hemorrhages from the lungs, and in the 
hemorrhagic sputum, on examination, will be found the organism 
of actinomycosis. 

4. LEPROSY. 

This is a chronic wound disease of a similar character to 
syphilis, tuberculosis, and actinomycosis. It is the result of the 
infection with a microorganism of the bacillus form. But it 
has the peculiarity that it causes from the very beginning a chronic, 
slow^ inflammation, which affects the body in two ways: (1) It 
affects the bod}^ in a similar way to syphilis, first producing ele- 
vations on the body, the so-called tubercous leprosy. (2) After- 
ward ulcerations form, these ulcerations being so chronic and ex- 
ceedingly poor in healing that they will not heal until some por- 
tions of the body affected have fallen off as necrotic parts. There- 
fore, one of the most characteristic appearances of the leprous 
person is that he has lost one of the phalanges of his fingers, 
portions of the elbows, the eyelids, etc., so that he is very much 
disfig-ured. 

Aftei* the patient has lost considerable of these projecting 
portions of the body, healing takes place, but with a tendency of 
the tissues to break down again very soon. Leprosy is characterized 
by one peculiarity, which is not found in s^^philis or in actinomycosis, 
and that is that it very often affects the nerve ends in such a way 
that they are paralyzed, this paralysis resulting in an insensibility 
so that the patients do not feel ; and the result of the loss of sensi- 
bility is that they lose the fingers, toes and parts of extremities, 
because of the fact that they do not feel any pain in them, and 

106 



da not know when the members are injured. They are usually 
patients of very little intelligence, as the disease is not found here, 
but in some countries where civilization is much lower, and they 
do not take any precaution against infection, and when leprotic 
infection and inflammation take place, the wound becomes infected, 
also, with streptococcic and staphylococcic infection, l^ot having 
any pain, the patients constantly injure the parts, until they 
finally lose these portions of the hands and feet. Pathologically 
the specimen of lepra shows the process of necrosis with scant 
attempt of the tissues to repair. 

5. CHRONIC, SEPTIC AND OTHER SEPTIC WOUND 

INFECTIONS. 
Any infections with other microorganisms may develop into a 
chronic inflammation with the tendency of the infiltration to form 
connective tissues and scar formation; we therefore speak of a 
chronic sepsis. 



ins 



GROUP IV. TUMORS. 

A tumor, or a neoplasm, is a new growth of tissue which 
has neither function nor purpose in the life of the individual, 
nor a typical or limited formation. Any tissue of the body under 
pathologic or even under physiologic conditions can grow excess- 
ively, but it will only develop within certain limits, defined by 
anatomic conformation of organs; for instance, a uterus grows 
immensely during pregnancy, its fibers and mucous membrane 
enlarge excessively, but the anatomical conformation and limits 
remain always those of a uterus. A biceps muscle, through hard 
work, may gTow immensely, but this growth will be limited to 
the anatomical shape of the biceps. 

These two cases are those of hyperplasia and hypertrophy, 
but if tissue develops within the uterus, its walls or surface, which 
does not conform to the anatomical shape, and is not limited, 
and has no ph3^siological purpose in its development, but is inde- 
pendent of the form and shape of the uterus, then we have to 
deal with a tumor of the uterus; or if fat develops in the surface 
of the biceps beyond the thickness of the panni cuius, in a lump, 
without purpose and limit, we have to deal with a tumor. 

Tumors are divided according to the cells and tissues of 
which they are composed, viz. : 

I. Connective tissue ] 
II. Epithelial }■ Tumors. 

III. Teratoma J 
1. Connective Tissue Tumoes : 

a. Fibroma, 

b. Lipoma, 

c. Myxoma, 

d. Chondroma, 

e. Osteoma, 

f. Myoma, 

g. Glioma, 

h. N"euroma, 

i. Lymphoma, 

j. Angioma (all the above are typical), 
k. Sarcoma (atypical). 

; 110 



2. Epithelial : 

a. Papilloma, 

b. Adenoma, 



I 



(Typical). 



c. Carcinoma (atypical). 
3. Teratoma. 

Etiology. The cause of the growth of tumors is, up to this 
time, not positively known, but some very probable theories have 
been advanced by pathologists. From all observations, it seems, 
however, that no simple and single cause, but some predisposition, 
and some determining causes are necessary to produce this new 
and unlimited growth of tissue. 

Trauma plays an important role, especially repeated trauma, 
even if the single effect be small; for instance, the smoking of 
a pipe is found to be an item in the history of nearly all cases of 
carcinoma of the lips. 

liemnants of embryonal tissue, which were lost, or remained 
dormant for a period of life, seem to be awakened to new and un- 
limited growth by some impulse (Cohnheim's theory). Such 
seems to be the case in the, new growth of enchondroma of the 
neck or cystic adenoma from remnants of the embryonal period. 

Finally, the parasitic theory has many followers, and there 
is a good deal of probability that some tumors may be caused by 
a parasite of some sort. Some pathologists have endeavored to 
show such organisms under the microscope and in the test tube. 
But, on the whole, the question of etiology must be left for the 
future. 



What effect has the growth of the tumor upon the neighboring 
tissues, and the organism as a whole? A new growth of such in- 
dependent character as a tumor will not remain without its effects 
locally, and general effects. By pressure and irritation it will 
cause inflammation. Leucocytic intiltration and formation of 
connective tissue will be the gradual result. This connective 
tissue formation often leads to the formation of capsules around 
tumors. By continuing to grow, tumors often produce pressure 
atrophy, or even necrosis. Some of the tumors do not remain 
confined to the place of first localization, but through lymph and 
blood current their elements are carried down the stream, and 
deposited as emboli in different places, where they begin to thrive 



COURSE AND EFFECTS OF TUMORS. 



112 



and grow into independent tumors (metastasis). The metastatic 
tumor has usually the same structure as the primary growth. The 
effect upon the individual in general must, in most of the cases of 
tumor growth, he a debilitating, weakening, inasmuch as it ab- 
stracts nourishment. Some of the tumors produce a cachexia 
(a combination of blood changes and toxine effects), which de- 
stroys the safety of life of the patient. 

A. CONNECTIVE TISSUE TUMORS. 
1. FIBROMA. 

The Fibeoma is a tumor consisting of connective tissue. 
This tissue is represented in the body by the connective tissue 
cell in its various forms, and its fiber; the tumor may be formed 
of both these elements. Fibromata are usually hard, nodular, 
globular masses, with a small amount of circulation, sometimes 
easily separable from the normal tissue by a loose capsule; at times 
closely adherent to the surrounding tissues. They may form in 
any part of the body where normally connective tissue is found. 

This tumor is usually harmless, unless it be so located as to 
press upon some vital organ. It does not form metastatic growths, 
that is, these tumors are not carried by the lymph or blood circu- 
lation, but they often do develop multiple. They may undergo 
all kinds of regressive changes, especially fatty and liquefying 
degeneration, which leads to cyst-like formation of the fibroma. 
On account of its poor nutrition, it often becomes necrotic. 

2. LIPOMA. 

Lipoma is the tumor of fat tissue, consisting of fat ceils. 
They form a more or less lobulated mass, which is easily sep- 
arated from the surrounding connective tissue by a loose capsule. 
The lipoma is a soft tumor, unless a great deal of connective tissue 
develops within the same (fibro-lipoma) . It is non-malignant, 
may develop not only where fat is present, under normal anatom- 
ical conditions, but also in places where there is no fat normally 
found, viz., brain, kidney. If located in the above-mentioned 
organs, severe symptoms may result. Lipomata way undergo all 
forms of regressive changes, like fibroma. The fat may yield an 
oily mass, with blood, producing green cysts. There is a lipomatus 
growth which is not so well defined, but grows into spaces of other 
tissues, infiltrating the same. It is found often on the neck — 

114 



DIFFUSE LiPOMATA. Lipoma also grows in large numbers, and, 
strangely, often symmetrically on the body (symmetrical lipoma). 

3. MYXOMA. 

The myxoma is a tumor consisting of a connective tissue, 
wherein the cells are separated by a mucous tissue. On micro- 
scopical examination, we hnd such a tumor appearing like a drop- 
sical subcutaneous tissue, viz., a gTcat deal of water and mucus, 
with very few formed cellular elements. Such tumors develop in 
the skin, fascia, muscles, bone, and marrow. They are often a 
part of a mixed tumor, in connection with chondroma, lipoma, 
fibroma, and others. As a rule, they do not form metastases. 

4. CHONDEOMA. 
The Chondroma is a tumor consisting of cartilage. Either 
variety, hyaline or fibrous, may compose such a tumor. It appears 
wherever cartilage is present in the body of the embryo or adult, 
and may therefore make its appearance in places where cartilage 
is not present in the adult, viz., in the parotid, and on the neck; 
rarely it also appears in places where no cartilage is normally 
present, viz., testicle. They are usually hard, unless changed by 
regressive metamorphosis. The regressive changes are softening 
processes within the chondroma. They are non-malignant, but 
sometimes form metastases. When the chondroma forms a small 
projection on the surface of cartilage or bone, we speak of an 

ECCHONDROSIS. 

5. OSTEOMA. 

The OSTEOMA is a tumor of bone substance. It may develop 
wherever bone or cartilage is present. If an osteoma develops in 
the form of a button or prominence, we speak of it as an 
EXOSTOSIS. Microscopically it shows the characteristic bone cell. 

Osteomata may consist of a very hard bone, or of cancelh:u3 
tissue, but it may also develop in places where no bone is present, 
as in the lung, skin, parotid, etc. It is non-malignant. 

6. MYOMA. 

The myoma is a tumor consisting of muscle. We distinguish 
(1) RHABDOMYOMA, and (2) LEIOMYOMA, respectively striated and 
non-striated muscle tumors. The leiomyoma is a very common 
tumor, which develops in connection with fibromata in many or- 

116 



gans containing non-striated muscle, especially in the uterus, and 
is here called i^^ibroid. It is more or less a globular tumor, with a 
capsule of loose connective tissue, with a poor degree of circulation, 
and consequently easily undergoes regressive changes, especially 
softening, it is non-malignant. 

The rhabdomyoma is a rare tumor, and is found especially in 
connection with other kinds of tumors in places where striated 
muscle normally is not present (kidney, testicle, vagina). 

7. GLIOMA. 

The GLIOMA is a tumor consisting of that connective tissue 
which forms the interstitial substance of the brain (glia). It is 
usually formed in the brain, and rarely in the spine, sometimes in 
the eye. Being very vascular, it may give rise to severe bleeding 
within the tumor tissue, with formation of cyst-like accumulations 
of fluid. The cells are numerous and easily undergo degenerative 
changes (softening) . It is a non-malignant growth, but may form 
metastasis. 

8. NEUROMA. 

The NEUROMA is a tumor consisting of new-formed nerve 
fibers. They are mostly spindle-shaped or oval enlargements of 
the nerve cell; some flat, others nodular. Very often numerous, 
and limited to certain nerve trunks (multiple neuromata). At 
times such nodules form in the brain or spinal cord. 

Microscopically, one will flnd new-formed,, poorly or well de- 
veloped fibers or cells. 

A peculiar form of neuroma is the amputation neuroma. 
After amputations of extremities there sometimes develops a bulb- 
ous enlargement of the nerve end, which is very painful, and which 
consists of enlarged and tortuous nerve fibers and new-formed con- 
nective tissue. A true neuroma, however, is the new formation 
of nerves in the course of the trunk of the nerve, which. is formed 
of fibers with marrow, or without such (neuro-myelinic and 

AMYELINIC neuroma). 

They are non-malignant, and form no metastases. 

9. LYMPHOMA. 

The lymphoma (true lymphoma) is a tumor consisting of 
lymphoid tissue, that is, a network (reticulum) with leucocytes. 
Very often enlarged glands, as a result of inflammation or hy per- 
ils 



plasia, are given this name ; but they lack the nature of the tumor, 
namely^ new growth without the definite anatomical configuration. 
Such lyniphomatous growths develop anywhere on a basis of 
lymphatic structures ; in glands, spleen, bone, marrow, etc. ; some- 
times even metastatic in places where anatomically lymphatic 
tissue is not present. 

10. ANGIOMA. 
The ANGiOMATA are tumors of blood vessels. We distinguisli 
anatomically several kinds of blood vessels, and from the varieties 
of these vessels which compose the tumor it obtains its name: A 
capillary or vascular nevus (winemark), a venous angioma, or 
arterial angioma (pulsating tumor). The nevus is composed of 
smallest vessels in subcutaneous tissue, which is transparent, hence 
the color of the vessels. A venous angioma is a skein of veins, with 
somewhat irregular walls, which are partly communicating. The 
vessel masses are transparent, soft and easily compressed. An 
arterial or erectile angioma is a complex of arteries with pulsa- 
tion. 

A peculiarity of the newly-formed blood vessels is that the 
arteries and veins forming it often lose their walls by a sort of 
pressure atrophy and communicate with each other, forming 
cavities. We speak of such as cavernous angioma. Angiomata 
may occur in any part of the body. They may be present at birth 
and grow rapidly after birth (birthmarks). They are not ma- 
lignant, except if they grow in places where they endanger the 
vital functions, viz., the brain; or they become dangerous because 
of the liabilitv to cause severe hemorrhage. They undergo changes 
of a regressive nature, become hardened by coagulation and or- 
ganization. 

A simple dilatation of a blood vessel for a short distance 
(sac-formed or cylindrical) is not a new growth, though it may 
have the shape of a tumor. A dilatation of a vein, for instance, 
is called varix; a dilatation of an artery, an aneurysm. The 
varix as well as the aneurysm may undergo changes through co- 
agulation within the lumen, stone formation (phleboliths) , or- 
ganizations and regressive changes, but all these changes are 
not tumors in the strict sense of the definition. 

11. LYMPHANGIOMA. 

The LYMPHANGIOMA IS a tumor consisting of lymphatic 

1^0 



vessels corresponding in its development to those of blood vessels. 
We speak of a nevus lymphaticus^ of cavernous lymphangioma^ 
etc. 

12. SAECOMA. 

The SARCOMA is a tumor consisting of a tissue which does not 
appear under normal conditions in the body of the adult. It is 
composed of cells of different character, all of which have one 
characteristic, namely, that of the connective tissue cell. This 
characteristic is shown by the presence of fibrous connections be- 
tween the cells composing the tumor. The cells themselves have 
nothing regular about their shape; some are small and round; 
others are large and round ; still others more spindle-shaped, small 
or large. Some of the cells are excessively large, with a great 
number of nuclei within the center of the cell body (giant cells). 

We distinguish several kinds of sarcoma according to the 
kind of cells. 

A tumor may be composed of several kinds of cells. The 
terms small and large round cell sarcoma, spindle and giant-celled 
sarcoma, indicate their composition. Very seldom the sarcoma 
has the structure of a gland that is of a more or less alveolar 
character, called alveolar sarcoma. These tumors are usually very 
vascular, and as a result of this vascularity grow very rapidly; 
sometimes the endothelium of the walls of the blood vessels them- 
selves multiplies with such rapidity and with the characteristic 
shape of sarcomatous cells that it becomes more or less a tumor 
of the endothelium (endothelioma). The vascularity of the 
sarcoma explains not only their rapid growth, but also their rapid 
spread over the body through the circulation (blood metastasis). 
It is characteristic of sarcoma that it spreads through the blood 
channels, and this is one of the reasons why sarcoma is one of the 
most malignant tumors of the bod}^ — another cause for its ma- 
lignancy is its rapid growth on the place of its first formation, 
and the softening effect it has on the tissue toward which it grows. 
Finally, it becomes so dangerous, because the cells find their way 
into the interstices of the tissues (infiltration-sarcoma). Sar- 
comatous blood A^essels have very thin walls, and often consist only 
of sarcomatous cells. This explains a feature of the sarcoma, 
namely, its tendencv to hemorrhage within the same, and its prone- 
ness to regressive changes. 

122 



Sarcomata easily become cystic and hemorrhagic. A peculiar 
variety of sarcoma is the melanosarcoma — black or brown pigment 
forming in the cell, or without, and gives to the tumor mass an 
appearance of black masses of tissue ; such tumors often develop on 
the basis of dark nevi, and from the choroidea. They belong to 
the most malignant, rapidly growing sarcomata. 

Macroscopically, the sarcoma shows a tumor mass of differ- 
ent character, irregular in shape, sometimes imitating the organ 
in which it has formed, sometimes disfiguring it. It has a differ- 
ent construction, according to the cells and vessels comprised, 
and if the arterial , circulation is very abundant, it may even 
pulsate. 

B. EPITHELIAL TUMOES. 
Epithelium may develop in the form of a tumor in two way«. 
It imitates more or less the anatomic structure of the tissue, which 
it composes (papilloma; adenoma), and develops irrespective of 
this structure into carcinoma. 

1. PAPILLOMA. 

The PAPILLOMA is a tumor of the skin or mucous membrane 
(consisting of epithelium of the same), forming hilly excrescences, 
composed of these cells. There is one important feature of th's 
cellular growth, that it never dips below the matrix line of the 
epithelial boundary. Upward, it may grow independently, forming 
large cauliflower growths, with easily disintegrated cells ; con- 
sequently, it easily falls apart and ulcerates. The skin and bladder 
are frequent locations. It is non-malignant, an dforms no metas- 
tasis. 

2. ADENOMA. 
The ADENOMA is a tumor consisting of epithelium imitating 
the type of a gland, without the limits of a gland. Such growths 
of the epithelium will remain physiologically unproductive, and 
have all the bad results of this irregular development of the epi- 
thelial structures. While the normal gland produces its secretions 
and empties the same through ducts or directly on the mucous 
membrane, the cells composing an adenoma will have no such 
physiological function. They have no typical arrangement. They 
easilv become distended with the secretions (cystic, cyst-adeno- 
ma), and easily become the seat of regressive changes. There is, how- 

124 



and easily become the seat of regressive changes. There is^ how- 
ever, one characteristic which distinguishes the adenoma from the 
other gronp of tumors; that is, the epithelial cells do not grow 
beyond a certain line, which divides the embryologic line of de- 
markation, namely, they remain localized within the structure, 
which is originally the seat of the glands. We call this the matrix 
line. 

The adenoma of the larynx will not invade the cartilage. 
It may through its growth cause softening by pressure atrophy, 
but no cell will be found within the same. If these glandular 
structures are _found within these tissues, beneath the matrix 
line, the adenoma becomes an adeno-caecinoma^ or an atypical 
groM'th. Adenoma, as such, is non-malignant. They undergo, as 
before said, regressive changes, especially colloid, cystic, and hem- 
orrhagic degenerations. They do not form metastases. 

3. CAECINOMA. 

The CARCINOMA is an atypical epithelial tumor. It consists 
of epithelial cells which grow irrespective of embryonal lines of 
demarkation. The epithelial cells will grow in number, singly or 
in groups, break through the tissues of any nature, infiltrate sp;^ces 
between connective tissue, growing through lymphatics, and l^lood 
vessels be transported on those roads throughout the body. They 
are spread, however, more by way of the lymphatic circulation 
than by the blood, and consequently form their first inetastases in 
glands. They may imitate glandular structure, alveolar carcino- 
ma, etc. The carcinomatous cells may be very much like the normal 
etc. The carcinomatous cells may be very much like the normal 
cell, but often it is disfigured, larger and irregular. Sometimes 
the cells develop in such shapes as to form nests of epithelial cells, 
appearing as if they were limited in room for their development, 
so that they had to crowed into a small body in which the cells are 
arranged like the leaves of an onion (epithelial pearls). 

We have different varieties of carcinoma, viz. : 

(1) Pavement or squamous epithelial carcinoma, a cancer 
which is especially characteristic of the epidermis, and shows often 
development of epithelial pearls. 

(2) Cylindrical epithelial carcinoma develops from the more 
cvlindrical epitheliated mucous membrane. 



126 



(3) Myeloid or medullar}^ carcinoma, in which there is a 
large amount of cells, with very little interstitial structure; there- 
fore, easily broken down and easily destroyed, soft and mushy 
tumors. 

(4) Scirrhus, in that there is a small amount of cellular 
elements comparatively, with a large amount of supporting struc- 
ture. Therefore, hard nodular tumors, with a tendency to cicatri- 
zation, and contraction and slow growth. 

Carcinomata very often show rapid regressive changes. They 
are tumors with varying circulation, some being very vascular, 
others less so. 

On account of the rapid growth of the epithelium, its nutri- 
tion becomes insufficient, and decay of the cells follows rapidly 
their development; such necrosis leads to ulceration. Carcinoma 
is very malignant, as a rule, by its destruction of tissue and metas- 
tasis, but it also becomes malignant by the development of certain 
poisonous elements, which show their influence upon the blood 
through destruction of hemoglobin, and other symptoms, commonly 
described as cachexia. 

C. MIXED TUMOBS. 

Nature does not know any types or exclusive growths of these 
tumors, but it happens that one kind of tumor may grow in the 
same mass with another variety. We call this a mixed tumor. 

There is another combination possible between tumors of the 
connective tissue and epithelial character. We have cases of fibro- 
chondro-sarcoma ; lipo-chondro-angioma ; angio-sarcoma-lipomat- 
odes; chondro-osteoma-angiomatodes, etc. These combinations ex- 
plain the structures, but say nothing less than that combinations of 
tumors are possible. 

D. TERATOMATA. 

These are no tumors in the strict sense of the word, but rem- 
nants of an embryologic development of abnormities. They are 
twins formed in such a manner that only one individual develops 
fully while the other remains a crippled defective mass of tissue, 
irregularly thrown together. This foetal inclusion of such an 
abnormity gives cause to development of tumor-like masses on 
different points of the body called teratomata and dermoids. 



128 



INDEX 

Actinomycosis 102 

Adenocarcinoma 126 

Adenoma 124 

Amjdoid Degeneration 26 

Amputation Neuroma 118 

Anasarca 16 

Anemia 10 

Aneurysm 120 

Angioma 120 

Anomalies of Blood Circulation 10 

Anomalies of Lymph Circulation 14 

Antitoxin 68 

Aplasia 16 

Argyria 22 

Arteriosclerosis 22 

Arthritis Urica 22 

Ascites 16 

Asphyxia, Local 22 

Atrophy 16 

Birthmark 120 

Cachexia 16 

Carcinoma 126 

Caseation 24 

Catarrh 32 

Cavernous Angioma 120 

Chalky Degeneration 22 

Cholesterine 18 

Chondroma = 116 

Cloudy Swelling 18 

Coagulation Necrosis 24 

Colloid Degeneration 18 

Croup 62 

Cyst 24 

Cystadenoma 124 

Demarcation 32 

Diphtheria 68 

Ecchymosis 12 

Edema 14 

Embolism 14 

Embryonal Cells 86 

Encystment 24 

Endothelioma 122 

Epidermization 52 

Epistaxis 12 

Erysipelas 66 

Exudate 32 

Fatty Degeneration 18 

Fibroid 22, 118 

Fibroma 114 

Gangrene, Dry 24 

Moist 24 

Giant Cells 86 

Glioma 118 

Granulations 48 

Granuloma 32, 52 

Gumma 102 

Hematoma 12 

Hematemesis 12 

Hematuria 12 

Hematocele 12 

Hematometra 12 

Hemothorax 12 

Hemopericard 12 

Hemin 20 



129 



Hematin 20 

Hemoglobin 20 

Hemophilia 40 

Hemorrhage 12 

Hemorrhagic Infarct 12 

Hyaline Degeneration 20 

Hydrops '. 16 

Hydropic Degeneration 18 

Hyperemia 10 

Hypoplasia 16 

Hyperplasia 26 

Hypertrophy . 26 

Icterus 22 

Inflammation 30 

Infiltration 30 

Karyokinesis 26, 40 

Leprosy 106 

Lipoma . 114 

Liquefaction 24 

Lupus 96 

Lymphangioma 120 

Lymphoma 118 

Lymphadenitis 66 

Lymphangitis 64 

Lymphorrhagia 16 

Lymphothorax 16 

Lymphascites 16 

Melanosarcoma 22 

Metrorrhagia 12 

Metastasis 66, 114 

Mucoid Degeneration 18 

Mummification . 24 

Myoma 116 

Myxoma 116 

Necrosis 22 

Necrobiosis 22 

Neuroma 118 

Nevus : 120 

Oilcyst 18 

Opisthotonus 76 

Osseous Degeneration 22 

Osteoma 116 

Papilloma 124 

Phleboliths 120 

Pigment 20 

Primary Union 40 

Pus 46 

Regeneration 24, 28 

Restitutio ad integrum 32 

Sarcoma 122 

Scar 24, 44 

Sclerosis 96 

vSeptic Infection ....60, 66 

Sequestration 32 

Suffusion 12 

Syphilis 96 

Tetanus ''4 

Thrombosis 14 

Teratoma 126 

Trismus 76 

Trophoneurosis 16 

Toxine 68 

Tuberculosis 82 

Tubercle 86 

Tumors » 110 

Wound Diseases 54 



130 



CATALOGUE OF BOOKS 

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90 WABASH AVENUE CHICAGO 



THE STUDENT'S HANDBOOK OF SURGICAL OPERATIONS. By 
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ELEMENTS OF SURGICAL DIAGNOSIS. By A. Pearce Gould, F. R. 
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THE PRINCIPLES OF SURGICAL PATHOLOGY. By Carl Beck, 
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geons and Chicago Collese of Dental Surgery, and Professor of Sur- 
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MEDICAL LABORATORY METHODS AND TESTS. By Herbert 
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"The author is the medical registrar of Guy's Hospital. He was led to 
the preparation of this little book by the fact that there was no small work 
dealing with the chemical and microscopical tests which are most useful to 



131 



medical men. The book deals not with the examination of patients, but with 
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It contains 152 pages, and is a very good description of the examination of 
urine, blood, sputum, pus. gastric contents, feces, together with the micro- 
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A MANUAL OF MEDICAL TREATMENT, OR CLINICAL THERA- 
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TUMORS: INNOCENT AND MALIGNANT. THEIR CLINICAL 
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THE LYMPHATICS. GENERAL ANATOMY. By G. Delamere. SPE- 
CIAL STUDY OF THE LYMPHATICS IN DIFFERENT POR- 
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edge concerning the lymphatic system— omnipresent, yet so little seen. We 



132 



bespeak for Mr. Leaf, who as a surgeon and anatomist is alive to the im- 
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Special circular gratis upon application. 

A SURGICAL HAND-BOOK FOR THE USE OF STUDENTS, PRAC- 
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CLINICAL METHODS : A Guide to the Practical Study of Aledicine. By 
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A MANUAL OF GYNECOLOGY. By D. Berry Hart, M. D., and A. H. 
Freeland Barbour, M. D. Sixth edition. 8vo, 736 pages with twelve 
colored plates and 359 wood cuts. Cloth, $6.00 net. 

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In preparing the sixth edition the authors, while keeping especially in 
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DISEASES OF THE SKIN: An Outline of the Principles and Practice of 
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133 



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?^IODERN MICROSCOPY. A Handbook for Beginners and Students. 
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A PHYSICIAN'S PRACTICAL GYNECOLOGY. By W. O. Henry, M. D., 
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THE SURGERY OF THE DISEASES OF THE APPENDIX VER- 
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Fistulse, Bilharzia, Foreign Bodies. Diseases of the Prostate. Disease^ 
of the Kidneys. One vol., 8vo, with thirty-one full page plates and 144 
engravings in the text. Cloth, net, $6.00. 



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